- 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
- $57.46 / $105.66 / $180.61
| Professional | | $57.46 | $105.66 | $180.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.94 / $141.01 / $250.32
| Professional | | $49.94 | $141.01 | $250.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.72 / $91.86 / $275.08
| Professional | | $30.72 | $91.86 | $275.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.88 / $164.14 / $271.12
| Professional | | $111.88 | $164.14 | $271.12 |