- 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
- $96.23 / $134.30 / $150.11
| Professional | | $96.23 | $134.30 | $150.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.05 / $160.06 / $238.32
| Professional | | $136.05 | $160.06 | $238.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.12 / $158.97 / $289.49
| Professional | | $101.12 | $158.97 | $289.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,417.00 / $4,915.00
| Facility | | $437.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.46 / $134.13 / $200.62
| Professional | | $89.46 | $134.13 | $200.62 |