- 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
- $92.73 / $129.37 / $205.23
| Professional | | $92.73 | $129.37 | $205.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.18 / $141.63 / $262.68
| Professional | | $101.18 | $141.63 | $262.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.72 / $191.35 / $276.89
| Professional | | $131.72 | $191.35 | $276.89 |
- 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
- $106.56 / $171.67 / $280.66
| Professional | | $106.56 | $171.67 | $280.66 |