- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.14 / $170.93 / $243.20
| Professional | | $115.14 | $170.93 | $243.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.06 / $239.50 / $333.68
| Professional | | $160.06 | $239.50 | $333.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.94 / $267.33 / $405.73
| Professional | | $156.94 | $267.33 | $405.73 |
- 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
- $179.25 / $281.24 / $435.82
| Professional | | $179.25 | $281.24 | $435.82 |