- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,487.59 / $5,467.56
| Facility | | $2,090.73 | $3,487.59 | $5,467.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.65 / $307.07 / $414.27
| Professional | | $226.65 | $307.07 | $414.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.96 / $360.90 / $559.85
| Professional | | $228.96 | $360.90 | $559.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.29 / $427.06 / $822.79
| Professional | | $274.29 | $427.06 | $822.79 |
- 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
- $330.30 / $446.49 / $751.17
| Professional | | $330.30 | $446.49 | $751.17 |