- 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
- $54.17 / $115.37 / $133.36
| Professional | | $54.17 | $115.37 | $133.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.16 / $121.86 / $212.15
| Professional | | $71.16 | $121.86 | $212.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.94 / $143.94 / $313.20
| Professional | | $73.94 | $143.94 | $313.20 |
- 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
- $113.84 / $187.48 / $338.59
| Professional | | $113.84 | $187.48 | $338.59 |