- 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
- $55.33 / $75.20 / $80.01
| Professional | | $55.33 | $75.20 | $80.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $142.51 / $142.51
| Professional | | $0.02 | $142.51 | $142.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.61 / $90.21 / $160.44
| Professional | | $73.61 | $90.21 | $160.44 |
- 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
- $59.34 / $96.92 / $142.71
| Professional | | $59.34 | $96.92 | $142.71 |