- 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
- $80.53 / $94.47 / $103.84
| Professional | | $80.53 | $94.47 | $103.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.67 / $100.80 / $163.66
| Professional | | $84.67 | $100.80 | $163.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.65 / $91.74 / $181.07
| Professional | | $56.65 | $91.74 | $181.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.66 / $87.11 / $138.13
| Professional | | $58.66 | $87.11 | $138.13 |