- 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
- $59.46 / $85.20 / $106.46
| Professional | | $59.46 | $85.20 | $106.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.55 / $101.58 / $155.60
| Professional | | $78.55 | $101.58 | $155.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.75 / $111.14 / $196.79
| Professional | | $91.75 | $111.14 | $196.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $4,915.00
| Facility | | $437.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.58 / $127.62 / $188.39
| Professional | | $82.58 | $127.62 | $188.39 |