- 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
- $57.54 / $107.15 / $204.17
| Professional | | $57.54 | $107.15 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $97.72 / $177.83
| Professional | | $54.95 | $97.72 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $134.90 / $251.19
| Professional | | $72.44 | $134.90 | $251.19 |
- 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
- $61.66 / $100.00 / $190.55
| Professional | | $61.66 | $100.00 | $190.55 |