- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.57 / $1,125.57 / $1,508.26
| Facility | | $1,125.57 | $1,125.57 | $1,508.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.57 / $1,125.57 / $1,125.57
| Professional | | $1,125.57 | $1,125.57 | $1,125.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.40 / $203.40 / $260.04
| Professional | | $203.40 | $203.40 | $260.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.93 / $908.10 / $3,138.00
| Facility | | $27.93 | $908.10 | $3,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.07 / $547.26 / $1,693.30
| Professional | | $444.07 | $547.26 | $1,693.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.91 / $518.97 / $1,440.80
| Professional | | $383.91 | $518.97 | $1,440.80 |