- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.50 / $2,815.00 / $4,464.23
| Facility | | $1,473.50 | $2,815.00 | $4,464.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.30 / $130.30 / $162.62
| Professional | | $130.30 | $130.30 | $162.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.00 / $437.13 / $873.06
| Facility | | $339.00 | $437.13 | $873.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.55 / $127.56 / $477.44
| Professional | | $57.55 | $127.56 | $477.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.19 / $131.66 / $131.66
| Professional | | $111.19 | $131.66 | $131.66 |