- 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
- $8.00 / $45.08 / $53.77
| Professional | | $8.00 | $45.08 | $53.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.44 / $162.93 / $277.60
| Facility | | $107.44 | $162.93 | $277.60 |
- 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
- $17.53 / $27.50 / $145.28
| Professional | | $17.53 | $27.50 | $145.28 |