- 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
- $288.51 / $384.22 / $509.61
| Professional | | $288.51 | $384.22 | $509.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.45 / $394.72 / $649.16
| Professional | | $310.45 | $394.72 | $649.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.74 / $533.16 / $698.75
| Professional | | $395.74 | $533.16 | $698.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.11 / $406.41 / $736.41
| Professional | | $275.11 | $406.41 | $736.41 |