- 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
- $104.65 / $164.61 / $227.12
| Professional | | $104.65 | $164.61 | $227.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.02 / $197.96 / $302.48
| Professional | | $139.02 | $197.96 | $302.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.90 / $222.23 / $431.20
| Professional | | $142.90 | $222.23 | $431.20 |
- 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
- $172.94 / $256.64 / $462.29
| Professional | | $172.94 | $256.64 | $462.29 |