- 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
- $84.12 / $149.97 / $198.29
| Professional | | $84.12 | $149.97 | $198.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.68 / $205.03 / $304.14
| Professional | | $133.68 | $205.03 | $304.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.65 / $217.28 / $373.84
| Professional | | $143.65 | $217.28 | $373.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.59 / $259.13 / $402.01
| Professional | | $158.59 | $259.13 | $402.01 |