- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $114.82 / $199.53
| Professional | | $97.72 | $114.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $112.20 / $204.17
| Professional | | $83.18 | $112.20 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,023.29 / $1,479.11
| Facility | | $1,000.00 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $102.33 / $154.88
| Professional | | $81.28 | $102.33 | $154.88 |