- 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
- $81.37 / $115.09 / $130.29
| Professional | | $81.37 | $115.09 | $130.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.49 / $137.05 / $201.99
| Professional | | $116.49 | $137.05 | $201.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.53 / $134.40 / $241.92
| Professional | | $83.53 | $134.40 | $241.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.68 / $118.37 / $199.33
| Professional | | $77.68 | $118.37 | $199.33 |