- 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
- $95.50 / $134.90 / $316.23
| Professional | | $95.50 | $134.90 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $114.82 / $177.83
| Professional | | $79.43 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $177.83 / $302.00
| Professional | | $109.65 | $177.83 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $147.91 / $245.47
| Professional | | $95.50 | $147.91 | $245.47 |