- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $114.82 / $234.42
| Professional | | $52.48 | $114.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $100.00 / $194.98
| Professional | | $54.95 | $100.00 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $128.82 / $269.15
| Professional | | $74.13 | $128.82 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $114.82 / $213.80
| Professional | | $61.66 | $114.82 | $213.80 |