- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $3,706.14 / $4,411.72
| Facility | | $1,518.41 | $3,706.14 | $4,411.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.28 / $149.47 / $221.10
| Professional | | $129.28 | $149.47 | $221.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.47 / $169.51 / $283.30
| Professional | | $122.47 | $169.51 | $283.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.57 / $238.40 / $302.49
| Professional | | $176.57 | $238.40 | $302.49 |
- 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
- $131.13 / $209.68 / $322.12
| Professional | | $131.13 | $209.68 | $322.12 |