- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $117.49 / $288.40
| Professional | | $47.86 | $117.49 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $66.07 / $186.21
| Professional | | $45.71 | $66.07 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $112.20 / $229.09
| Professional | | $44.67 | $112.20 | $229.09 |