- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $7,259.54
| Facility | | $2,090.73 | $3,706.14 | $7,259.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.36 / $176.95 / $177.64
| Professional | | $121.36 | $176.95 | $177.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.52 / $186.49 / $309.39
| Professional | | $158.52 | $186.49 | $309.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.45 / $255.75 / $366.58
| Professional | | $120.45 | $255.75 | $366.58 |
- 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
- $140.91 / $221.09 / $374.90
| Professional | | $140.91 | $221.09 | $374.90 |