- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,511.24 / $3,932.74 / $3,937.50
| Facility | | $1,511.24 | $3,932.74 | $3,937.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.57 / $246.68 / $341.32
| Professional | | $155.57 | $246.68 | $341.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.60 / $297.58 / $400.13
| Professional | | $185.60 | $297.58 | $400.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $310.66 / $617.79
| Professional | | $150.00 | $310.66 | $617.79 |
- 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
- $254.10 / $412.35 / $647.11
| Professional | | $254.10 | $412.35 | $647.11 |