- 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
- $81.73 / $129.75 / $161.69
| Professional | | $81.73 | $129.75 | $161.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.12 / $160.00 / $258.27
| Professional | | $84.12 | $160.00 | $258.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.60 / $191.48 / $380.21
| Professional | | $100.60 | $191.48 | $380.21 |
- 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
- $132.35 / $218.26 / $351.87
| Professional | | $132.35 | $218.26 | $351.87 |