- 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
- $156.88 / $278.27 / $402.49
| Professional | | $156.88 | $278.27 | $402.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.76 / $398.70 / $715.87
| Professional | | $192.76 | $398.70 | $715.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.76 / $342.54 / $727.86
| Professional | | $192.76 | $342.54 | $727.86 |
- 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
- $340.48 / $494.50 / $657.55
| Professional | | $340.48 | $494.50 | $657.55 |