- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,019.95 / $3,981.07
| Facility | | $1,513.56 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $70.79 / $186.21
| Professional | | $30.20 | $70.79 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $70.79 / $109.65
| Professional | | $31.62 | $70.79 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $83.18 / $177.83
| Professional | | $38.90 | $83.18 | $177.83 |
- 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
- $33.11 / $61.66 / $158.49
| Professional | | $33.11 | $61.66 | $158.49 |