- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $684.83 / $1,738.02 / $3,706.14
| Facility | | $684.83 | $1,738.02 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.64 / $100.95 / $135.71
| Professional | | $56.64 | $100.95 | $135.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.84 / $120.69 / $176.76
| Professional | | $74.84 | $120.69 | $176.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.70 / $171.10 / $264.25
| Professional | | $107.70 | $171.10 | $264.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.58 / $183.16 / $290.01
| Professional | | $112.58 | $183.16 | $290.01 |