- 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
- $102.95 / $120.13 / $193.48
| Professional | | $102.95 | $120.13 | $193.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.69 / $140.74 / $254.42
| Professional | | $101.69 | $140.74 | $254.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.29 / $195.86 / $241.83
| Professional | | $141.29 | $195.86 | $241.83 |
- 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
- $104.30 / $159.01 / $258.63
| Professional | | $104.30 | $159.01 | $258.63 |