- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.95 / $2,778.87 / $3,955.04
| Facility | | $1,477.95 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.22 / $124.80 / $187.77
| Professional | | $90.22 | $124.80 | $187.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $155.91 / $183.56
| Professional | | $106.24 | $155.91 | $183.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.45 / $170.66 / $247.71
| Professional | | $105.45 | $170.66 | $247.71 |
- 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
- $116.64 / $155.65 / $263.64
| Professional | | $116.64 | $155.65 | $263.64 |