- 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
- $169.72 / $174.17 / $193.52
| Professional | | $169.72 | $174.17 | $193.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.57 / $208.90 / $307.06
| Professional | | $177.57 | $208.90 | $307.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.15 / $263.31 / $368.67
| Professional | | $155.15 | $263.31 | $368.67 |
- 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
- $180.38 / $255.55 / $394.83
| Professional | | $180.38 | $255.55 | $394.83 |