- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.44 / $3,781.66 / $3,781.66
| Facility | | $2,219.44 | $3,781.66 | $3,781.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.24 / $157.24 / $157.24
| Facility | | $157.24 | $157.24 | $157.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,384.13 / $4,384.13 / $4,384.13
| Professional | | $4,384.13 | $4,384.13 | $4,384.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $4,551.00 / $5,409.00
| Professional | | $155.00 | $4,551.00 | $5,409.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.00 / $1,464.00 / $2,720.00
| Facility | | $658.00 | $1,464.00 | $2,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.41 / $48.41 / $48.41
| Professional | | $48.41 | $48.41 | $48.41 |