- 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
- $58.58 / $140.27 / $342.11
| Professional | | $58.58 | $140.27 | $342.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.72 / $196.06 / $449.67
| Professional | | $115.72 | $196.06 | $449.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.63 / $210.13 / $613.25
| Professional | | $72.63 | $210.13 | $613.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.79 / $412.43 / $639.66
| Professional | | $297.79 | $412.43 | $639.66 |