- 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
- $60.40 / $86.04 / $119.51
| Professional | | $60.40 | $86.04 | $119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.81 / $105.76 / $189.92
| Professional | | $71.81 | $105.76 | $189.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.98 / $131.07 / $175.79
| Professional | | $84.98 | $131.07 | $175.79 |
- 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
- $79.20 / $115.31 / $206.71
| Professional | | $79.20 | $115.31 | $206.71 |