- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $4,265.80
| Facility | | $1,513.56 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $354.81
| Professional | | $107.15 | $151.36 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $144.54 / $190.55
| Professional | | $102.33 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $275.42
| Professional | | $112.20 | $169.82 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $239.88
| Professional | | $100.00 | $144.54 | $239.88 |