- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,009.22 / $2,145.03 / $5,495.72
| Facility | | $1,009.22 | $2,145.03 | $5,495.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.41 / $264.61 / $872.58
| Professional | | $154.41 | $264.61 | $872.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.74 / $201.72 / $339.57
| Professional | | $145.74 | $201.72 | $339.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.12 / $360.29 / $1,064.07
| Professional | | $210.12 | $360.29 | $1,064.07 |
- 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
- $164.89 / $313.61 / $884.53
| Professional | | $164.89 | $313.61 | $884.53 |