- 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
- $148.53 / $280.17 / $715.64
| Professional | | $148.53 | $280.17 | $715.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.88 / $414.23 / $591.76
| Professional | | $167.88 | $414.23 | $591.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.52 / $324.39 / $1,289.90
| Professional | | $178.52 | $324.39 | $1,289.90 |
- 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
- $569.86 / $894.11 / $1,165.48
| Professional | | $569.86 | $894.11 | $1,165.48 |