- 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
- $224.09 / $295.26 / $392.94
| Professional | | $224.09 | $295.26 | $392.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.29 / $309.30 / $501.09
| Professional | | $243.29 | $309.30 | $501.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.44 / $409.02 / $538.54
| Professional | | $298.44 | $409.02 | $538.54 |
- 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
- $208.62 / $311.23 / $563.04
| Professional | | $208.62 | $311.23 | $563.04 |