- 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
- $82.43 / $119.16 / $120.40
| Professional | | $82.43 | $119.16 | $120.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.50 / $130.00 / $200.08
| Professional | | $110.50 | $130.00 | $200.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.12 / $160.57 / $233.24
| Professional | | $113.12 | $160.57 | $233.24 |
- 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
- $98.26 / $157.93 / $247.69
| Professional | | $98.26 | $157.93 | $247.69 |