- 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
- $38.60 / $39.59 / $52.51
| Professional | | $38.60 | $39.59 | $52.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.29 / $47.41 / $96.12
| Professional | | $40.29 | $47.41 | $96.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.72 / $71.12 / $80.48
| Professional | | $39.72 | $71.12 | $80.48 |
- 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
- $39.20 / $60.69 / $450.46
| Professional | | $39.20 | $60.69 | $450.46 |