- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.92 / $2,105.73 / $3,955.04
| Facility | | $571.92 | $2,105.73 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.89 / $109.84 / $166.44
| Professional | | $59.89 | $109.84 | $166.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.96 / $145.66 / $231.36
| Professional | | $101.96 | $145.66 | $231.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.49 / $150.00 / $295.67
| Professional | | $101.49 | $150.00 | $295.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.38 / $177.39 / $293.92
| Professional | | $116.38 | $177.39 | $293.92 |