- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $3,296.37 / $3,955.04
| Facility | | $1,518.41 | $3,296.37 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.74 / $224.07 / $290.33
| Professional | | $170.74 | $224.07 | $290.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.45 / $278.81 / $360.51
| Professional | | $195.45 | $278.81 | $360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $325.19 / $462.67
| Professional | | $150.00 | $325.19 | $462.67 |
- 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
- $177.97 / $320.70 / $495.85
| Professional | | $177.97 | $320.70 | $495.85 |