- 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
- $85.07 / $110.60 / $140.62
| Professional | | $85.07 | $110.60 | $140.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.84 / $113.80 / $207.35
| Professional | | $94.84 | $113.80 | $207.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.15 / $114.98 / $206.71
| Professional | | $65.15 | $114.98 | $206.71 |
- 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
- $66.80 / $117.64 / $156.13
| Professional | | $66.80 | $117.64 | $156.13 |