- 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
- $267.55 / $315.35 / $484.46
| Professional | | $267.55 | $315.35 | $484.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.43 / $378.26 / $619.62
| Professional | | $295.43 | $378.26 | $619.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.04 / $504.47 / $664.06
| Professional | | $380.04 | $504.47 | $664.06 |
- 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
- $279.58 / $397.98 / $702.90
| Professional | | $279.58 | $397.98 | $702.90 |