- 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
- $39.74 / $54.28 / $78.17
| Professional | | $39.74 | $54.28 | $78.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.61 / $45.42 / $103.80
| Professional | | $38.61 | $45.42 | $103.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.65 / $55.09 / $90.62
| Professional | | $29.65 | $55.09 | $90.62 |
- 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
- $43.74 / $64.81 / $107.14
| Professional | | $43.74 | $64.81 | $107.14 |