- 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
- $120.06 / $189.49 / $268.95
| Professional | | $120.06 | $189.49 | $268.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.22 / $256.98 / $361.91
| Professional | | $164.22 | $256.98 | $361.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.09 / $274.14 / $435.11
| Professional | | $168.09 | $274.14 | $435.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.46 / $271.38 / $467.76
| Professional | | $149.46 | $271.38 | $467.76 |