- 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
- $247.96 / $326.05 / $513.51
| Professional | | $247.96 | $326.05 | $513.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.60 / $450.43 / $661.32
| Professional | | $317.60 | $450.43 | $661.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.66 / $458.60 / $798.61
| Professional | | $310.66 | $458.60 | $798.61 |
- 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
- $316.91 / $483.74 / $766.35
| Professional | | $316.91 | $483.74 | $766.35 |