- 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
- $13.78 / $15.60 / $18.55
| Professional | | $13.78 | $15.60 | $18.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.45 / $18.17 / $27.89
| Professional | | $13.45 | $18.17 | $27.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.16 / $20.23 / $37.50
| Professional | | $17.16 | $20.23 | $37.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.30 / $24.33 / $38.72
| Professional | | $15.30 | $24.33 | $38.72 |