- 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
- $32.49 / $43.69 / $62.95
| Professional | | $32.49 | $43.69 | $62.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.07 / $34.20 / $86.54
| Professional | | $29.07 | $34.20 | $86.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.84 / $43.35 / $73.38
| Professional | | $22.84 | $43.35 | $73.38 |
- 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
- $37.20 / $53.91 / $87.78
| Professional | | $37.20 | $53.91 | $87.78 |