- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $3,706.14 / $5,111.70
| Facility | | $1,518.41 | $3,706.14 | $5,111.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.73 / $249.27 / $359.34
| Professional | | $184.73 | $249.27 | $359.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.61 / $346.58 / $486.57
| Professional | | $242.61 | $346.58 | $486.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.95 / $358.84 / $591.37
| Professional | | $219.95 | $358.84 | $591.37 |
- 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
- $248.16 / $409.92 / $675.29
| Professional | | $248.16 | $409.92 | $675.29 |