- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $190.55 / $549.54
| Professional | | $70.79 | $190.55 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $346.74 / $1,148.15
| Professional | | $186.21 | $346.74 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $218.78 / $602.56
| Professional | | $75.86 | $218.78 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $794.33 / $3,235.94
| Facility | | $776.25 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $263.03 / $575.44
| Professional | | $87.10 | $263.03 | $575.44 |