- 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
- $90.71 / $117.61 / $172.64
| Professional | | $90.71 | $117.61 | $172.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.43 / $153.56 / $220.22
| Professional | | $111.43 | $153.56 | $220.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.95 / $174.58 / $246.97
| Professional | | $124.95 | $174.58 | $246.97 |
- 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
- $103.44 / $165.30 / $272.81
| Professional | | $103.44 | $165.30 | $272.81 |