- 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
- $137.68 / $212.28 / $270.64
| Professional | | $137.68 | $212.28 | $270.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.25 / $252.88 / $418.93
| Professional | | $208.25 | $252.88 | $418.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.82 / $289.83 / $425.95
| Professional | | $238.82 | $289.83 | $425.95 |
- 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
- $171.71 / $262.69 / $460.89
| Professional | | $171.71 | $262.69 | $460.89 |