- 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
- $110.84 / $134.91 / $168.65
| Professional | | $110.84 | $134.91 | $168.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.46 / $171.92 / $235.84
| Professional | | $109.46 | $171.92 | $235.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.08 / $205.83 / $349.41
| Professional | | $149.08 | $205.83 | $349.41 |
- 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
- $131.31 / $198.77 / $356.45
| Professional | | $131.31 | $198.77 | $356.45 |