- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.04 / $2,778.87 / $3,955.04
| Facility | | $1,245.04 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.43 / $162.09 / $202.54
| Professional | | $103.43 | $162.09 | $202.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.18 / $212.12 / $327.94
| Professional | | $135.18 | $212.12 | $327.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.21 / $254.90 / $477.24
| Professional | | $161.21 | $254.90 | $477.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $4,915.00
| Facility | | $437.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.49 / $297.66 / $430.82
| Professional | | $177.49 | $297.66 | $430.82 |