- 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
- $42.46 / $78.93 / $97.67
| Professional | | $42.46 | $78.93 | $97.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.27 / $88.43 / $174.49
| Professional | | $53.27 | $88.43 | $174.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.36 / $107.33 / $249.36
| Professional | | $53.36 | $107.33 | $249.36 |
- 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
- $76.64 / $144.69 / $227.19
| Professional | | $76.64 | $144.69 | $227.19 |