- 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
- $39.92 / $65.73 / $85.73
| Professional | | $39.92 | $65.73 | $85.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $77.00 / $101.49
| Professional | | $47.53 | $77.00 | $101.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.23 / $90.14 / $140.65
| Professional | | $51.23 | $90.14 | $140.65 |
- 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
- $64.75 / $75.92 / $147.74
| Professional | | $64.75 | $75.92 | $147.74 |