- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.88 / $288.85 / $388.08
| Professional | | $158.88 | $288.85 | $388.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.46 / $307.22 / $552.27
| Professional | | $180.46 | $307.22 | $552.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.34 / $374.71 / $780.20
| Professional | | $182.34 | $374.71 | $780.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.30 / $472.28 / $701.28
| Professional | | $331.30 | $472.28 | $701.28 |