- 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
- $116.45 / $132.87 / $302.73
| Professional | | $116.45 | $132.87 | $302.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.06 / $224.49 / $308.87
| Professional | | $137.06 | $224.49 | $308.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.34 / $236.15 / $533.33
| Professional | | $97.34 | $236.15 | $533.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.99 / $289.56 / $388.08
| Professional | | $179.99 | $289.56 | $388.08 |