- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,955.04 / $4,483.05
| Facility | | $2,090.73 | $3,955.04 | $4,483.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.88 / $219.18 / $370.48
| Professional | | $129.88 | $219.18 | $370.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.49 / $296.52 / $425.54
| Professional | | $198.49 | $296.52 | $425.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.28 / $334.98 / $511.57
| Professional | | $194.28 | $334.98 | $511.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.82 / $354.60 / $548.24
| Professional | | $247.82 | $354.60 | $548.24 |