- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,101.67 / $3,955.04
| Facility | | $2,090.73 | $3,101.67 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.70 / $121.27 / $161.22
| Professional | | $91.70 | $121.27 | $161.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.81 / $151.43 / $226.88
| Professional | | $97.81 | $151.43 | $226.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.09 / $172.43 / $327.39
| Professional | | $115.09 | $172.43 | $327.39 |
- 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
- $119.91 / $204.20 / $296.70
| Professional | | $119.91 | $204.20 | $296.70 |