- 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
- $54.57 / $95.31 / $118.08
| Professional | | $54.57 | $95.31 | $118.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.59 / $110.39 / $200.49
| Professional | | $63.59 | $110.39 | $200.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.81 / $133.66 / $295.38
| Professional | | $65.81 | $133.66 | $295.38 |
- 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
- $95.91 / $147.86 / $274.02
| Professional | | $95.91 | $147.86 | $274.02 |