- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,750.82 / $4,246.00 / $8,031.00
| Facility | | $1,750.82 | $4,246.00 | $8,031.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.70 / $90.83 / $97.28
| Professional | | $85.70 | $90.83 | $97.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.00 / $509.80 / $711.57
| Professional | | $425.00 | $509.80 | $711.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.00 / $3,983.00 / $6,832.00
| Facility | | $1,347.00 | $3,983.00 | $6,832.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.23 / $94.22 / $154.47
| Professional | | $65.23 | $94.22 | $154.47 |