- 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
- $197.47 / $232.78 / $332.05
| Professional | | $197.47 | $232.78 | $332.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.34 / $282.89 / $426.13
| Professional | | $209.34 | $282.89 | $426.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.72 / $363.17 / $464.21
| Professional | | $275.72 | $363.17 | $464.21 |
- 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
- $180.81 / $315.20 / $487.26
| Professional | | $180.81 | $315.20 | $487.26 |