- 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
- $170.20 / $226.75 / $283.11
| Professional | | $170.20 | $226.75 | $283.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.04 / $237.25 / $359.63
| Professional | | $174.04 | $237.25 | $359.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.90 / $301.70 / $388.48
| Professional | | $239.90 | $301.70 | $388.48 |
- 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
- $142.32 / $265.24 / $393.60
| Professional | | $142.32 | $265.24 | $393.60 |