- 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
- $55.36 / $80.40 / $105.55
| Professional | | $55.36 | $80.40 | $105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.76 / $101.16 / $150.66
| Professional | | $63.76 | $101.16 | $150.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.89 / $121.11 / $220.65
| Professional | | $76.89 | $121.11 | $220.65 |
- 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
- $86.88 / $137.62 / $193.09
| Professional | | $86.88 | $137.62 | $193.09 |