- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $204.17 / $338.84
| Professional | | $100.00 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $208.93 / $371.54
| Professional | | $104.71 | $208.93 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,174.90 / $1,174.90
| Facility | | $446.68 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $234.42 / $501.19
| Professional | | $120.23 | $234.42 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $199.53 / $354.81
| Professional | | $102.33 | $199.53 | $354.81 |