- 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
- $62.00 / $110.95 / $137.76
| Professional | | $62.00 | $110.95 | $137.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.95 / $123.27 / $217.21
| Professional | | $73.95 | $123.27 | $217.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.78 / $147.38 / $317.10
| Professional | | $73.78 | $147.38 | $317.10 |
- 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
- $110.74 / $175.18 / $295.37
| Professional | | $110.74 | $175.18 | $295.37 |