- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $2,130.83 / $3,955.04
| Facility | | $1,518.41 | $2,130.83 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.37 / $147.61 / $209.84
| Professional | | $93.37 | $147.61 | $209.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.00 / $218.55 / $272.20
| Professional | | $153.00 | $218.55 | $272.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.56 / $265.64 / $394.49
| Professional | | $107.56 | $265.64 | $394.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.70 / $236.68 / $379.80
| Professional | | $185.70 | $236.68 | $379.80 |