- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,946.66 / $3,178.47 / $5,300.66
| Facility | | $1,946.66 | $3,178.47 | $5,300.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.62 / $318.22 / $2,160.00
| Professional | | $256.62 | $318.22 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.48 / $60.64 / $179.83
| Professional | | $45.48 | $60.64 | $179.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.99 / $562.99 / $837.43
| Facility | | $562.99 | $562.99 | $837.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |