- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.05 / $1,518.41 / $3,955.04
| Facility | | $982.05 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.40 / $155.72 / $270.33
| Professional | | $103.40 | $155.72 | $270.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.50 / $183.74 / $284.27
| Professional | | $121.50 | $183.74 | $284.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.62 / $244.74 / $335.29
| Professional | | $169.62 | $244.74 | $335.29 |
- 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
- $153.44 / $243.66 / $377.99
| Professional | | $153.44 | $243.66 | $377.99 |