- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,740.83 / $2,778.87 / $3,955.04
| Facility | | $1,740.83 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.64 / $130.75 / $168.22
| Professional | | $108.64 | $130.75 | $168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $181.61 / $247.38
| Professional | | $119.58 | $181.61 | $247.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.16 / $194.66 / $352.02
| Professional | | $140.16 | $194.66 | $352.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.97 / $195.04 / $318.05
| Professional | | $128.97 | $195.04 | $318.05 |