- 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
- $206.34 / $302.76 / $493.49
| Professional | | $206.34 | $302.76 | $493.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.33 / $509.65 / $511.18
| Professional | | $300.33 | $509.65 | $511.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.40 / $432.04 / $886.89
| Professional | | $208.40 | $432.04 | $886.89 |
- 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
- $292.05 / $520.73 / $668.52
| Professional | | $292.05 | $520.73 | $668.52 |