- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.70 / $3,977.00 / $5,743.00
| Facility | | $1,058.70 | $3,977.00 | $5,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.75 / $2,738.76 / $4,417.10
| Professional | | $547.75 | $2,738.76 | $4,417.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.45 / $1,334.02 / $1,944.04
| Facility | | $1,029.45 | $1,334.02 | $1,944.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,649.00 / $2,824.00
| Facility | | $1,106.00 | $1,649.00 | $2,824.00 |