- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.68 / $1,543.03 / $3,955.04
| Facility | | $341.68 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.72 / $161.84 / $217.84
| Professional | | $124.72 | $161.84 | $217.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.69 / $209.31 / $267.35
| Professional | | $144.69 | $209.31 | $267.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.46 / $231.02 / $348.74
| Professional | | $139.46 | $231.02 | $348.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.74 / $241.74 / $368.33
| Professional | | $170.74 | $241.74 | $368.33 |