- 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
- $148.88 / $237.57 / $370.74
| Professional | | $148.88 | $237.57 | $370.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.03 / $265.19 / $428.25
| Professional | | $163.03 | $265.19 | $428.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.87 / $324.45 / $499.57
| Professional | | $229.87 | $324.45 | $499.57 |
- 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
- $198.78 / $346.28 / $538.61
| Professional | | $198.78 | $346.28 | $538.61 |