- 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
- $13.60 / $13.60 / $39.04
| Professional | | $13.60 | $13.60 | $39.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,387.61 / $8,286.60 / $10,056.70
| Facility | | $5,387.61 | $8,286.60 | $10,056.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.29 / $59.55 / $126.16
| Professional | | $28.29 | $59.55 | $126.16 |