- 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
- $53.29 / $98.50 / $112.37
| Professional | | $53.29 | $98.50 | $112.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.03 / $371.03 / $412.26
| Facility | | $371.03 | $371.03 | $412.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.17 / $139.02 / $214.63
| Professional | | $84.17 | $139.02 | $214.63 |