- 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
- $135.08 / $177.59 / $216.06
| Professional | | $135.08 | $177.59 | $216.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.38 / $187.15 / $281.41
| Professional | | $136.38 | $187.15 | $281.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.29 / $238.39 / $301.00
| Professional | | $181.29 | $238.39 | $301.00 |
- 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
- $119.68 / $209.94 / $322.70
| Professional | | $119.68 | $209.94 | $322.70 |