- 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
- $104.78 / $200.32 / $218.90
| Professional | | $104.78 | $200.32 | $218.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.74 / $204.40 / $318.77
| Professional | | $173.74 | $204.40 | $318.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.11 / $234.69 / $361.87
| Professional | | $167.11 | $234.69 | $361.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.90 / $213.72 / $352.53
| Professional | | $168.90 | $213.72 | $352.53 |