- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,971.64 / $3,706.14 / $3,955.04
| Facility | | $1,971.64 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.92 / $105.81 / $160.74
| Professional | | $58.92 | $105.81 | $160.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.34 / $118.83 / $185.02
| Professional | | $66.34 | $118.83 | $185.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.70 / $123.88 / $199.53
| Professional | | $88.70 | $123.88 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.33 / $116.33 / $228.10
| Professional | | $73.33 | $116.33 | $228.10 |