- 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
- $59.97 / $80.76 / $85.70
| Professional | | $59.97 | $80.76 | $85.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.23 / $141.53 / $202.18
| Professional | | $75.23 | $141.53 | $202.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.92 / $98.69 / $142.71
| Professional | | $60.92 | $98.69 | $142.71 |