- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.36 / $1,543.03 / $3,955.04
| Facility | | $783.36 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.15 / $154.77 / $207.93
| Professional | | $129.15 | $154.77 | $207.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.44 / $216.35 / $289.75
| Professional | | $151.44 | $216.35 | $289.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.97 / $227.84 / $418.47
| Professional | | $163.97 | $227.84 | $418.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.11 / $234.34 / $379.63
| Professional | | $154.11 | $234.34 | $379.63 |