- 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
- $200.78 / $246.60 / $340.05
| Professional | | $200.78 | $246.60 | $340.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.16 / $297.17 / $436.09
| Professional | | $216.16 | $297.17 | $436.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.64 / $375.05 / $479.85
| Professional | | $273.64 | $375.05 | $479.85 |
- 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
- $190.79 / $271.75 / $486.88
| Professional | | $190.79 | $271.75 | $486.88 |