- 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
- $83.77 / $125.69 / $172.86
| Professional | | $83.77 | $125.69 | $172.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.70 / $143.27 / $233.61
| Professional | | $89.70 | $143.27 | $233.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.88 / $177.54 / $335.49
| Professional | | $108.88 | $177.54 | $335.49 |
- 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
- $125.20 / $196.47 / $308.60
| Professional | | $125.20 | $196.47 | $308.60 |