- 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
- $124.46 / $171.12 / $214.71
| Professional | | $124.46 | $171.12 | $214.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.59 / $177.17 / $289.14
| Professional | | $150.59 | $177.17 | $289.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.08 / $240.42 / $360.76
| Professional | | $205.08 | $240.42 | $360.76 |
- 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
- $155.84 / $300.02 / $407.40
| Professional | | $155.84 | $300.02 | $407.40 |