- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.46 / $140.13 / $147.82
| Professional | | $88.46 | $140.13 | $147.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.96 / $121.14 / $132.91
| Facility | | $99.96 | $121.14 | $132.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.32 / $163.59 / $254.35
| Professional | | $98.32 | $163.59 | $254.35 |