- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $239.88
| Professional | | $100.00 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $147.91 / $218.78
| Professional | | $109.65 | $147.91 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $173.78 / $323.59
| Professional | | $109.65 | $173.78 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,238.72 / $6,606.93
| Facility | | $575.44 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $138.04 / $245.47
| Professional | | $100.00 | $138.04 | $245.47 |