- 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
- $56.77 / $103.18 / $140.79
| Professional | | $56.77 | $103.18 | $140.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $144.77 / $164.08
| Professional | | $0.02 | $144.77 | $164.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,401.00 / $4,915.00
| Facility | | $437.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.16 / $127.44 / $199.51
| Professional | | $85.16 | $127.44 | $199.51 |