- 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
- $66.30 / $85.78 / $105.84
| Professional | | $66.30 | $85.78 | $105.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.87 / $103.47 / $164.38
| Professional | | $45.87 | $103.47 | $164.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.45 / $109.49 / $224.58
| Professional | | $54.45 | $109.49 | $224.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,199.00 / $4,915.00
| Facility | | $437.00 | $1,199.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.62 / $129.05 / $207.66
| Professional | | $81.62 | $129.05 | $207.66 |