- 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
- $115.73 / $168.43 / $244.88
| Professional | | $115.73 | $168.43 | $244.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.17 / $258.05 / $287.93
| Professional | | $174.17 | $258.05 | $287.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.86 / $205.12 / $438.51
| Professional | | $119.86 | $205.12 | $438.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.27 / $227.03 / $319.08
| Professional | | $143.27 | $227.03 | $319.08 |