- 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
- $57.32 / $72.56 / $97.20
| Professional | | $57.32 | $72.56 | $97.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $97.52 / $140.78
| Professional | | $69.84 | $97.52 | $140.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.12 / $107.09 / $197.54
| Professional | | $74.12 | $107.09 | $197.54 |
- 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
- $74.17 / $100.05 / $179.94
| Professional | | $74.17 | $100.05 | $179.94 |