- 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
- $203.16 / $237.59 / $345.01
| Professional | | $203.16 | $237.59 | $345.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.19 / $280.32 / $437.77
| Professional | | $214.19 | $280.32 | $437.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.52 / $358.34 / $475.59
| Professional | | $279.52 | $358.34 | $475.59 |
- 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
- $166.39 / $329.66 / $510.13
| Professional | | $166.39 | $329.66 | $510.13 |