- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.01 / $175.22 / $270.02
| Professional | | $154.01 | $175.22 | $270.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.01 / $210.40 / $359.69
| Professional | | $152.01 | $210.40 | $359.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.29 / $289.12 / $360.29
| Professional | | $211.29 | $289.12 | $360.29 |
- 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
- $155.84 / $233.49 / $385.36
| Professional | | $155.84 | $233.49 | $385.36 |