- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $141.25 / $302.00
| Professional | | $75.86 | $141.25 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $125.89 / $190.55
| Professional | | $81.28 | $125.89 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $120.23 / $194.98
| Professional | | $81.28 | $120.23 | $194.98 |