- 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
- $40.74 / $72.44 / $131.83
| Professional | | $40.74 | $72.44 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $64.57 / $107.15
| Professional | | $37.15 | $64.57 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $89.13 / $151.36
| Professional | | $47.86 | $89.13 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $74.13 / $123.03
| Professional | | $42.66 | $74.13 | $123.03 |