- 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
- $131.34 / $192.31 / $232.25
| Professional | | $131.34 | $192.31 | $232.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.12 / $242.71 / $325.63
| Professional | | $193.12 | $242.71 | $325.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.77 / $214.63 / $418.18
| Professional | | $135.77 | $214.63 | $418.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.12 / $291.26 / $342.66
| Professional | | $145.12 | $291.26 | $342.66 |