- 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
- $85.75 / $131.44 / $185.27
| Professional | | $85.75 | $131.44 | $185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.76 / $178.02 / $275.89
| Professional | | $118.76 | $178.02 | $275.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.45 / $209.68 / $384.29
| Professional | | $115.45 | $209.68 | $384.29 |
- 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
- $144.27 / $239.68 / $412.37
| Professional | | $144.27 | $239.68 | $412.37 |