- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.45 / $1,450.18 / $3,706.14
| Facility | | $1,217.45 | $1,450.18 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.43 / $180.14 / $238.46
| Professional | | $167.43 | $180.14 | $238.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.89 / $211.63 / $406.73
| Professional | | $179.89 | $211.63 | $406.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.62 / $296.77 / $361.32
| Professional | | $148.62 | $296.77 | $361.32 |
- 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
- $180.81 / $247.82 / $345.15
| Professional | | $180.81 | $247.82 | $345.15 |