- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $138.04 / $331.13
| Professional | | $100.00 | $138.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $120.23 / $229.09
| Professional | | $104.71 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $194.98 / $239.88
| Professional | | $125.89 | $194.98 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $257.04
| Professional | | $104.71 | $154.88 | $257.04 |