- 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
- $110.07 / $221.74 / $298.58
| Professional | | $110.07 | $221.74 | $298.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.91 / $269.86 / $451.32
| Professional | | $180.91 | $269.86 | $451.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.65 / $289.80 / $604.46
| Professional | | $186.65 | $289.80 | $604.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.57 / $418.99 / $683.14
| Professional | | $221.57 | $418.99 | $683.14 |