- 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
- $28.57 / $58.57 / $77.18
| Professional | | $28.57 | $58.57 | $77.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.64 / $64.40 / $153.02
| Professional | | $32.64 | $64.40 | $153.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.96 / $80.59 / $216.07
| Professional | | $39.96 | $80.59 | $216.07 |
- 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
- $60.02 / $111.09 / $216.75
| Professional | | $60.02 | $111.09 | $216.75 |