- 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
- $184.69 / $257.94 / $319.24
| Professional | | $184.69 | $257.94 | $319.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.82 / $301.10 / $485.36
| Professional | | $177.82 | $301.10 | $485.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.62 / $408.32 / $701.35
| Professional | | $239.62 | $408.32 | $701.35 |
- 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
- $258.43 / $425.59 / $753.17
| Professional | | $258.43 | $425.59 | $753.17 |