- 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
- $24.78 / $26.16 / $33.71
| Professional | | $24.78 | $26.16 | $33.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.76 / $25.60 / $50.67
| Professional | | $21.76 | $25.60 | $50.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.60 / $131.60 / $131.60
| Facility | | $131.60 | $131.60 | $131.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.86 / $34.19 / $53.47
| Professional | | $25.86 | $34.19 | $53.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.07 / $31.44 / $45.74
| Professional | | $27.07 | $31.44 | $45.74 |