- 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
- $6.76 / $18.48 / $23.44
| Professional | | $6.76 | $18.48 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.12 / $119.63 / $145.28
| Facility | | $64.12 | $119.63 | $145.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.79 / $13.38 / $32.90
| Professional | | $6.79 | $13.38 | $32.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.43 / $21.43 / $21.43
| Professional | | $21.43 | $21.43 | $21.43 |
- 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
- $16.45 / $27.22 / $45.87
| Professional | | $16.45 | $27.22 | $45.87 |