- 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
- $229.66 / $288.70 / $393.13
| Professional | | $229.66 | $288.70 | $393.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.54 / $373.71 / $531.91
| Professional | | $247.54 | $373.71 | $531.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.78 / $389.86 / $620.04
| Professional | | $220.78 | $389.86 | $620.04 |
- 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
- $263.51 / $429.80 / $666.08
| Professional | | $263.51 | $429.80 | $666.08 |