- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $131.83 / $309.03
| Professional | | $46.77 | $131.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $79.43 / $147.91
| Professional | | $39.81 | $79.43 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $117.49 / $257.04
| Professional | | $56.23 | $117.49 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,412.54 / $6,456.54
| Facility | | $416.87 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $91.20 / $208.93
| Professional | | $48.98 | $91.20 | $208.93 |