- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,111.20 / $1,518.41 / $3,955.04
| Facility | | $1,111.20 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.35 / $167.68 / $198.83
| Professional | | $132.35 | $167.68 | $198.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.73 / $142.62 / $288.86
| Professional | | $90.73 | $142.62 | $288.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.75 / $199.76 / $320.89
| Professional | | $121.75 | $199.76 | $320.89 |
- 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
- $128.47 / $200.15 / $289.02
| Professional | | $128.47 | $200.15 | $289.02 |