- 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
- $166.60 / $262.44 / $412.15
| Professional | | $166.60 | $262.44 | $412.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.68 / $291.63 / $479.99
| Professional | | $182.68 | $291.63 | $479.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.95 / $353.52 / $553.45
| Professional | | $258.95 | $353.52 | $553.45 |
- 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
- $220.06 / $345.19 / $596.11
| Professional | | $220.06 | $345.19 | $596.11 |