- 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
- $87.10 / $125.89 / $316.23
| Professional | | $87.10 | $125.89 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $109.65 / $173.78
| Professional | | $83.18 | $109.65 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $158.49 / $234.42
| Professional | | $89.13 | $158.49 | $234.42 |
- 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
- $87.10 / $131.83 / $204.17
| Professional | | $87.10 | $131.83 | $204.17 |