- 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
- $240.30 / $300.57 / $435.48
| Professional | | $240.30 | $300.57 | $435.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.47 / $337.43 / $556.78
| Professional | | $263.47 | $337.43 | $556.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.13 / $454.19 / $597.22
| Professional | | $338.13 | $454.19 | $597.22 |
- 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
- $252.72 / $417.38 / $631.61
| Professional | | $252.72 | $417.38 | $631.61 |