- 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
- $75.48 / $116.24 / $157.36
| Professional | | $75.48 | $116.24 | $157.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.05 / $129.60 / $209.38
| Professional | | $82.05 | $129.60 | $209.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.50 / $159.12 / $304.47
| Professional | | $98.50 | $159.12 | $304.47 |
- 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
- $110.92 / $178.18 / $285.58
| Professional | | $110.92 | $178.18 | $285.58 |