- 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
- $26.51 / $38.47 / $40.14
| Professional | | $26.51 | $38.47 | $40.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.51 / $40.60 / $68.36
| Professional | | $34.51 | $40.60 | $68.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.50 / $57.26 / $180.00
| Professional | | $41.50 | $57.26 | $180.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.84 / $49.96 / $83.35
| Professional | | $31.84 | $49.96 | $83.35 |