- 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
- $235.03 / $308.18 / $409.26
| Professional | | $235.03 | $308.18 | $409.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.44 / $326.41 / $520.76
| Professional | | $254.44 | $326.41 | $520.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.04 / $419.92 / $561.79
| Professional | | $309.04 | $419.92 | $561.79 |
- 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
- $228.54 / $398.41 / $605.32
| Professional | | $228.54 | $398.41 | $605.32 |