- 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
- $141.15 / $190.56 / $273.64
| Professional | | $141.15 | $190.56 | $273.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.66 / $190.98 / $366.03
| Professional | | $152.66 | $190.98 | $366.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.45 / $197.66 / $330.46
| Professional | | $105.45 | $197.66 | $330.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.36 / $225.55 / $270.58
| Professional | | $115.36 | $225.55 | $270.58 |