- 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
- $75.86 / $100.00 / $245.47
| Professional | | $75.86 | $100.00 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $85.11 / $147.91
| Professional | | $64.57 | $85.11 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $128.82 / $186.21
| Professional | | $75.86 | $128.82 | $186.21 |
- 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
- $75.86 / $107.15 / $162.18
| Professional | | $75.86 | $107.15 | $162.18 |