- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.19 / $1,007.19 / $6,907.00
| Facility | | $1,007.19 | $1,007.19 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.81 / $141.96 / $191.38
| Professional | | $89.81 | $141.96 | $191.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.06 / $219.96 / $310.60
| Professional | | $120.06 | $219.96 | $310.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,985.46 / $1,985.46 / $3,192.10
| Facility | | $1,985.46 | $1,985.46 | $3,192.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.82 / $210.66 / $334.20
| Professional | | $119.82 | $210.66 | $334.20 |