- 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
- $121.51 / $177.69 / $244.43
| Professional | | $121.51 | $177.69 | $244.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.99 / $217.85 / $331.24
| Professional | | $152.99 | $217.85 | $331.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.71 / $251.74 / $479.97
| Professional | | $159.71 | $251.74 | $479.97 |
- 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
- $189.85 / $277.60 / $437.13
| Professional | | $189.85 | $277.60 | $437.13 |