- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,713.00 / $3,176.50 / $4,346.23
| Facility | | $1,713.00 | $3,176.50 | $4,346.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.92 / $92.92 / $115.15
| Professional | | $92.92 | $92.92 | $115.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.46 / $311.27 / $621.69
| Facility | | $241.46 | $311.27 | $621.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.70 / $121.70 / $269.76
| Professional | | $85.70 | $121.70 | $269.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.97 / $60.29 / $101.96
| Professional | | $34.97 | $60.29 | $101.96 |