- 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
- $70.16 / $100.50 / $155.91
| Professional | | $70.16 | $100.50 | $155.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.47 / $150.66 / $247.44
| Professional | | $105.47 | $150.66 | $247.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.08 / $187.11 / $264.98
| Professional | | $101.08 | $187.11 | $264.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.00 / $179.68 / $277.52
| Professional | | $104.00 | $179.68 | $277.52 |