- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $2,425.29 / $3,955.04
| Facility | | $1,518.41 | $2,425.29 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.31 / $38.99 / $46.13
| Professional | | $25.31 | $38.99 | $46.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $51.58 / $81.12
| Professional | | $29.38 | $51.58 | $81.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.83 / $66.64 / $109.95
| Professional | | $37.83 | $66.64 | $109.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.00 / $1,183.00 / $4,915.00
| Facility | | $320.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.65 / $56.37 / $96.68
| Professional | | $36.65 | $56.37 | $96.68 |