- 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
- $93.76 / $135.31 / $167.10
| Professional | | $93.76 | $135.31 | $167.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.46 / $171.73 / $231.87
| Professional | | $139.46 | $171.73 | $231.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.53 / $153.96 / $304.11
| Professional | | $97.53 | $153.96 | $304.11 |
- 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
- $99.81 / $163.29 / $231.03
| Professional | | $99.81 | $163.29 | $231.03 |