- 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
- $56.90 / $108.13 / $154.81
| Professional | | $56.90 | $108.13 | $154.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.31 / $125.50 / $202.78
| Professional | | $64.31 | $125.50 | $202.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.58 / $157.30 / $287.39
| Professional | | $89.58 | $157.30 | $287.39 |
- 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
- $125.34 / $204.56 / $289.08
| Professional | | $125.34 | $204.56 | $289.08 |