- 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
- $85.11 / $131.83 / $398.11
| Professional | | $85.11 | $131.83 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $112.20 / $177.83
| Professional | | $77.62 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $158.49 / $251.19
| Professional | | $89.13 | $158.49 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $141.25 / $204.17
| Professional | | $89.13 | $141.25 | $204.17 |