- 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
- $150.88 / $210.44 / $290.80
| Professional | | $150.88 | $210.44 | $290.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.87 / $226.89 / $373.28
| Professional | | $177.87 | $226.89 | $373.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.79 / $278.05 / $399.18
| Professional | | $193.79 | $278.05 | $399.18 |
- 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
- $166.75 / $279.32 / $423.44
| Professional | | $166.75 | $279.32 | $423.44 |