- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $7,719.54
| Facility | | $2,090.73 | $3,706.14 | $7,719.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.84 / $95.45 / $122.16
| Professional | | $67.84 | $95.45 | $122.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.20 / $114.23 / $181.50
| Professional | | $74.20 | $114.23 | $181.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.81 / $135.53 / $259.98
| Professional | | $86.81 | $135.53 | $259.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.57 / $141.38 / $274.64
| Professional | | $90.57 | $141.38 | $274.64 |