- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $25,703.96 / $25,703.96
| Facility | | $1,513.56 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $177.83 / $446.68
| Professional | | $102.33 | $177.83 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $239.88
| Professional | | $107.15 | $151.36 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $229.09 / $302.00
| Professional | | $141.25 | $229.09 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $177.83 / $288.40
| Professional | | $112.20 | $177.83 | $288.40 |