- 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
- $48.82 / $70.09 / $104.19
| Professional | | $48.82 | $70.09 | $104.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.75 / $92.39 / $123.60
| Professional | | $58.75 | $92.39 | $123.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.33 / $99.84 / $162.49
| Professional | | $54.33 | $99.84 | $162.49 |
- 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
- $72.33 / $112.63 / $171.18
| Professional | | $72.33 | $112.63 | $171.18 |