- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.63 / $2,090.73 / $3,955.04
| Facility | | $1,587.63 | $2,090.73 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.17 / $267.85 / $373.06
| Professional | | $112.17 | $267.85 | $373.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.35 / $286.17 / $544.88
| Professional | | $153.35 | $286.17 | $544.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.26 / $272.77 / $552.48
| Professional | | $160.26 | $272.77 | $552.48 |
- 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
- $251.10 / $384.49 / $593.20
| Professional | | $251.10 | $384.49 | $593.20 |