- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.58 / $1,518.41 / $3,955.04
| Facility | | $1,088.58 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.25 / $135.28 / $181.82
| Professional | | $102.25 | $135.28 | $181.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.38 / $176.26 / $223.73
| Professional | | $123.38 | $176.26 | $223.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.63 / $208.22 / $299.27
| Professional | | $122.63 | $208.22 | $299.27 |
- 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
- $132.22 / $207.45 / $357.99
| Professional | | $132.22 | $207.45 | $357.99 |