- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $793.55 / $1,543.03 / $5,038.24
| Facility | | $793.55 | $1,543.03 | $5,038.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.91 / $105.25 / $158.72
| Professional | | $64.91 | $105.25 | $158.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.02 / $139.58 / $208.51
| Professional | | $94.02 | $139.58 | $208.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.28 / $140.10 / $249.06
| Professional | | $90.28 | $140.10 | $249.06 |
- 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
- $112.12 / $172.64 / $225.98
| Professional | | $112.12 | $172.64 | $225.98 |