- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.27 / $112.37 / $310.38
| Professional | | $27.27 | $112.37 | $310.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.39 / $228.72 / $371.03
| Facility | | $105.39 | $228.72 | $371.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.14 / $105.39 / $105.39
| Professional | | $76.14 | $105.39 | $105.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.26 / $137.51 / $214.92
| Professional | | $83.26 | $137.51 | $214.92 |