- 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
- $52.74 / $106.01 / $144.87
| Professional | | $52.74 | $106.01 | $144.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.77 / $112.65 / $186.28
| Professional | | $70.77 | $112.65 | $186.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.55 / $136.91 / $276.02
| Professional | | $72.55 | $136.91 | $276.02 |
- 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
- $103.60 / $167.23 / $257.22
| Professional | | $103.60 | $167.23 | $257.22 |