- 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
- $170.88 / $244.83 / $280.24
| Professional | | $170.88 | $244.83 | $280.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.10 / $290.70 / $433.14
| Professional | | $247.10 | $290.70 | $433.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.89 / $285.56 / $507.86
| Professional | | $182.89 | $285.56 | $507.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,401.00 / $4,915.00
| Facility | | $437.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.60 / $291.12 / $377.40
| Professional | | $197.60 | $291.12 | $377.40 |