- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.54 / $142.21 / $194.73
| Professional | | $82.54 | $142.21 | $194.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.81 / $153.03 / $245.27
| Professional | | $109.81 | $153.03 | $245.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.45 / $186.41 / $364.15
| Professional | | $110.45 | $186.41 | $364.15 |
- 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
- $140.21 / $222.58 / $346.61
| Professional | | $140.21 | $222.58 | $346.61 |