- 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
- $118.78 / $124.34 / $163.00
| Professional | | $118.78 | $124.34 | $163.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.65 / $141.94 / $251.70
| Professional | | $120.65 | $141.94 | $251.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.68 / $206.81 / $275.14
| Professional | | $101.68 | $206.81 | $275.14 |
- 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
- $128.47 / $176.08 / $246.43
| Professional | | $128.47 | $176.08 | $246.43 |