- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.27 / $2,770.20 / $3,955.04
| Facility | | $1,717.27 | $2,770.20 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.39 / $201.24 / $278.08
| Professional | | $123.39 | $201.24 | $278.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.68 / $297.77 / $421.01
| Professional | | $189.68 | $297.77 | $421.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.83 / $324.58 / $514.72
| Professional | | $191.83 | $324.58 | $514.72 |
- 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
- $188.67 / $356.78 / $551.80
| Professional | | $188.67 | $356.78 | $551.80 |