- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $112.20 / $331.13
| Professional | | $57.54 | $112.20 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $112.20 / $199.53
| Professional | | $67.61 | $112.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $158.49 / $275.42
| Professional | | $79.43 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $128.82 / $229.09
| Professional | | $67.61 | $128.82 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $112.20 / $309.03
| Professional | | $56.23 | $112.20 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $131.83 / $229.09
| Professional | | $69.18 | $131.83 | $229.09 |