- 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
- $191.96 / $261.27 / $365.12
| Professional | | $191.96 | $261.27 | $365.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.43 / $262.19 / $461.88
| Professional | | $189.43 | $262.19 | $461.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.27 / $355.14 / $450.14
| Professional | | $263.27 | $355.14 | $450.14 |
- 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
- $193.36 / $302.13 / $481.43
| Professional | | $193.36 | $302.13 | $481.43 |