- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,538.50 / $3,538.50 / $3,538.50
| Facility | | $3,538.50 | $3,538.50 | $3,538.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.75 / $2,378.19 / $2,616.01
| Professional | | $1,963.75 | $2,378.19 | $2,616.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.65 / $249.32 / $394.96
| Facility | | $65.65 | $249.32 | $394.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.44 / $78.40 / $156.31
| Professional | | $76.44 | $78.40 | $156.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,088.81 / $3,694.42 / $4,303.79
| Facility | | $3,088.81 | $3,694.42 | $4,303.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.07 / $1,215.43 / $3,108.09
| Facility | | $1,042.07 | $1,215.43 | $3,108.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.36 / $1,256.84 / $7,344.00
| Professional | | $116.36 | $1,256.84 | $7,344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.36 / $1,239.33 / $2,212.33
| Professional | | $116.36 | $1,239.33 | $2,212.33 |