- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $2,223.59 / $3,955.04
| Facility | | $1,518.41 | $2,223.59 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.43 / $109.45 / $244.28
| Professional | | $23.43 | $109.45 | $244.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.57 / $35.22 / $141.97
| Professional | | $25.57 | $35.22 | $141.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.31 / $69.58 / $423.21
| Professional | | $33.31 | $69.58 | $423.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.20 / $62.92 / $367.71
| Professional | | $29.20 | $62.92 | $367.71 |