- 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
- $14.79 / $37.74 / $51.01
| Professional | | $14.79 | $37.74 | $51.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.88 / $26.67 / $78.54
| Professional | | $15.88 | $26.67 | $78.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.73 / $42.25 / $128.91
| Professional | | $16.73 | $42.25 | $128.91 |
- 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
- $26.53 / $64.23 / $113.45
| Professional | | $26.53 | $64.23 | $113.45 |