- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,794.42 / $5,583.54 / $5,583.54
| Facility | | $4,794.42 | $5,583.54 | $5,583.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.91 / $117.82 / $182.92
| Professional | | $82.91 | $117.82 | $182.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.88 / $119.86 / $200.51
| Professional | | $101.88 | $119.86 | $200.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.70 / $146.03 / $238.83
| Professional | | $103.70 | $146.03 | $238.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.66 / $148.05 / $227.00
| Professional | | $89.66 | $148.05 | $227.00 |