- 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
- $87.08 / $112.36 / $146.07
| Professional | | $87.08 | $112.36 | $146.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.98 / $139.82 / $177.08
| Professional | | $99.98 | $139.82 | $177.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.27 / $161.51 / $228.48
| Professional | | $100.27 | $161.51 | $228.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.89 / $158.37 / $260.30
| Professional | | $87.89 | $158.37 | $260.30 |