- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,379.86 / $1,543.03 / $3,955.04
| Facility | | $1,379.86 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.39 / $202.49 / $290.89
| Professional | | $115.39 | $202.49 | $290.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $292.32 / $506.73
| Professional | | $143.31 | $292.32 | $506.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $246.61 / $524.85
| Professional | | $143.31 | $246.61 | $524.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $2,445.00 / $4,602.00
| Facility | | $1,069.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.45 / $312.00 / $502.34
| Professional | | $254.45 | $312.00 | $502.34 |