- 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
- $70.31 / $97.17 / $135.55
| Professional | | $70.31 | $97.17 | $135.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.51 / $142.56 / $201.19
| Professional | | $89.51 | $142.56 | $201.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.35 / $161.76 / $296.66
| Professional | | $108.35 | $161.76 | $296.66 |
- 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
- $119.24 / $156.47 / $246.70
| Professional | | $119.24 | $156.47 | $246.70 |