- 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
- $52.72 / $75.25 / $167.73
| Professional | | $52.72 | $75.25 | $167.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.50 / $94.57 / $175.88
| Professional | | $61.50 | $94.57 | $175.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.45 / $104.45 / $189.17
| Professional | | $59.45 | $104.45 | $189.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $3,774.00
| Facility | | $437.00 | $1,183.00 | $3,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.56 / $125.71 / $191.55
| Professional | | $71.56 | $125.71 | $191.55 |