- 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
- $177.22 / $212.58 / $289.02
| Professional | | $177.22 | $212.58 | $289.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.77 / $303.97 / $584.29
| Professional | | $152.77 | $303.97 | $584.29 |
- 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
- $175.84 / $263.33 / $418.36
| Professional | | $175.84 | $263.33 | $418.36 |