- 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
- $52.90 / $85.47 / $112.00
| Professional | | $52.90 | $85.47 | $112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.23 / $108.20 / $180.92
| Professional | | $55.23 | $108.20 | $180.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.18 / $130.93 / $281.70
| Professional | | $65.18 | $130.93 | $281.70 |
- 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
- $89.41 / $137.44 / $234.27
| Professional | | $89.41 | $137.44 | $234.27 |