- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.85 / $146.47 / $194.13
| Professional | | $104.85 | $146.47 | $194.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $192.62 / $271.49
| Professional | | $134.83 | $192.62 | $271.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $226.97 / $385.35
| Professional | | $163.22 | $226.97 | $385.35 |
- 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
- $144.94 / $215.91 / $363.20
| Professional | | $144.94 | $215.91 | $363.20 |