- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.51 / $2,830.05 / $4,179.76
| Facility | | $1,242.51 | $2,830.05 | $4,179.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.36 / $252.88 / $348.22
| Professional | | $113.36 | $252.88 | $348.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.69 / $288.25 / $512.41
| Professional | | $155.69 | $288.25 | $512.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.91 / $276.38 / $516.02
| Professional | | $162.91 | $276.38 | $516.02 |
- 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
- $234.09 / $357.68 / $553.76
| Professional | | $234.09 | $357.68 | $553.76 |