- 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
- $28.35 / $58.48 / $75.55
| Professional | | $28.35 | $58.48 | $75.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.75 / $53.58 / $101.96
| Professional | | $26.75 | $53.58 | $101.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.56 / $69.17 / $147.44
| Professional | | $32.56 | $69.17 | $147.44 |
- 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
- $58.90 / $91.97 / $135.50
| Professional | | $58.90 | $91.97 | $135.50 |