- 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
- $221.11 / $286.64 / $407.72
| Professional | | $221.11 | $286.64 | $407.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.29 / $388.52 / $652.13
| Professional | | $242.29 | $388.52 | $652.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.31 / $424.51 / $612.53
| Professional | | $216.31 | $424.51 | $612.53 |
- 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
- $260.44 / $424.58 / $657.80
| Professional | | $260.44 | $424.58 | $657.80 |