- 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
- $212.32 / $252.84 / $335.14
| Professional | | $212.32 | $252.84 | $335.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.42 / $317.74 / $410.66
| Professional | | $222.42 | $317.74 | $410.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.28 / $381.71 / $524.82
| Professional | | $241.28 | $381.71 | $524.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $4,915.00
| Facility | | $437.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.54 / $363.78 / $533.98
| Professional | | $264.54 | $363.78 | $533.98 |