- 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
- $47.86 / $79.43 / $141.25
| Professional | | $47.86 | $79.43 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $72.44 / $114.82
| Professional | | $43.65 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $100.00 / $165.96
| Professional | | $48.98 | $100.00 | $165.96 |
- 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
- $53.70 / $83.18 / $138.04
| Professional | | $53.70 | $83.18 | $138.04 |