- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $937.28 / $2,254.27 / $2,441.67
| Facility | | $937.28 | $2,254.27 | $2,441.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.65 / $184.89 / $202.15
| Professional | | $41.65 | $184.89 | $202.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.58 / $197.22 / $224.83
| Professional | | $107.58 | $197.22 | $224.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.56 / $162.03 / $606.02
| Professional | | $127.56 | $162.03 | $606.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.52 / $295.82 / $369.78
| Professional | | $246.52 | $295.82 | $369.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $110.93 / $197.10
| Professional | | $103.54 | $110.93 | $197.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.26 / $195.98 / $195.98
| Professional | | $123.26 | $195.98 | $195.98 |