- 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
- $151.22 / $250.00 / $261.38
| Professional | | $151.22 | $250.00 | $261.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.09 / $76.58 / $124.76
| Professional | | $65.09 | $76.58 | $124.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.71 / $168.10 / $265.25
| Professional | | $100.71 | $168.10 | $265.25 |
- 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
- $60.35 / $112.14 / $179.42
| Professional | | $60.35 | $112.14 | $179.42 |