- 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
- $47.64 / $76.53 / $173.07
| Professional | | $47.64 | $76.53 | $173.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.10 / $107.21 / $225.44
| Professional | | $53.10 | $107.21 | $225.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.58 / $143.30 / $346.36
| Professional | | $79.58 | $143.30 | $346.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.94 / $238.93 / $343.30
| Professional | | $146.94 | $238.93 | $343.30 |