- 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
- $238.14 / $490.32 / $596.92
| Professional | | $238.14 | $490.32 | $596.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.07 / $319.38 / $955.77
| Professional | | $256.07 | $319.38 | $955.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.26 / $418.20 / $709.95
| Professional | | $180.26 | $418.20 | $709.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.26 / $508.01 / $818.22
| Professional | | $387.26 | $508.01 | $818.22 |