- 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
- $67.53 / $118.62 / $221.06
| Professional | | $67.53 | $118.62 | $221.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.42 / $145.00 / $210.54
| Professional | | $75.42 | $145.00 | $210.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.58 / $186.77 / $261.67
| Professional | | $90.58 | $186.77 | $261.67 |
- 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
- $113.95 / $182.32 / $344.46
| Professional | | $113.95 | $182.32 | $344.46 |