- 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
- $65.44 / $86.82 / $116.84
| Professional | | $65.44 | $86.82 | $116.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.76 / $105.95 / $137.79
| Professional | | $73.76 | $105.95 | $137.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.15 / $130.66 / $174.37
| Professional | | $77.15 | $130.66 | $174.37 |
- 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
- $77.04 / $120.87 / $177.64
| Professional | | $77.04 | $120.87 | $177.64 |