- 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
- $184.90 / $188.12 / $240.92
| Professional | | $184.90 | $188.12 | $240.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.05 / $228.29 / $459.30
| Professional | | $194.05 | $228.29 | $459.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.45 / $339.96 / $392.42
| Professional | | $192.45 | $339.96 | $392.42 |
- 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
- $188.65 / $258.37 / $426.40
| Professional | | $188.65 | $258.37 | $426.40 |