- 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
- $55.07 / $85.40 / $114.12
| Professional | | $55.07 | $85.40 | $114.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.66 / $100.53 / $133.55
| Professional | | $65.66 | $100.53 | $133.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.38 / $110.02 / $166.11
| Professional | | $71.38 | $110.02 | $166.11 |
- 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
- $83.37 / $115.13 / $171.00
| Professional | | $83.37 | $115.13 | $171.00 |