- 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
- $38.90 / $77.62 / $190.55
| Professional | | $38.90 | $77.62 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $67.61 / $117.49
| Professional | | $57.54 | $67.61 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $109.65 / $158.49
| Professional | | $50.12 | $109.65 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $95.50 / $151.36
| Professional | | $67.61 | $95.50 | $151.36 |