- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,897.79 / $4,897.79
| Facility | | $1,513.56 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $144.54 / $275.42
| Professional | | $61.66 | $144.54 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $123.03 / $245.47
| Professional | | $67.61 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $151.36 / $354.81
| Professional | | $79.43 | $151.36 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $151.36 / $288.40
| Professional | | $72.44 | $151.36 | $288.40 |