- 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
- $25.41 / $58.54 / $76.61
| Professional | | $25.41 | $58.54 | $76.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.72 / $58.58 / $146.09
| Professional | | $29.72 | $58.58 | $146.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.79 / $70.81 / $205.57
| Professional | | $35.79 | $70.81 | $205.57 |
- 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
- $58.34 / $100.35 / $185.75
| Professional | | $58.34 | $100.35 | $185.75 |