- 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
- $235.96 / $308.23 / $415.77
| Professional | | $235.96 | $308.23 | $415.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.24 / $327.95 / $533.71
| Professional | | $257.24 | $327.95 | $533.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.93 / $426.93 / $570.66
| Professional | | $301.93 | $426.93 | $570.66 |
- 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
- $233.46 / $407.00 / $617.82
| Professional | | $233.46 | $407.00 | $617.82 |