- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.26 / $2,359.80 / $3,706.14
| Facility | | $1,478.26 | $2,359.80 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.05 / $132.28 / $208.81
| Professional | | $67.05 | $132.28 | $208.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.77 / $164.73 / $281.61
| Professional | | $98.77 | $164.73 | $281.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.35 / $175.65 / $356.87
| Professional | | $117.35 | $175.65 | $356.87 |
- 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
- $178.28 / $235.26 / $372.20
| Professional | | $178.28 | $235.26 | $372.20 |