- 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
- $97.89 / $119.43 / $144.69
| Professional | | $97.89 | $119.43 | $144.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.75 / $154.43 / $203.37
| Professional | | $121.75 | $154.43 | $203.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.64 / $134.85 / $262.23
| Professional | | $84.64 | $134.85 | $262.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $154.15 / $197.85
| Professional | | $92.43 | $154.15 | $197.85 |