- 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
- $81.28 / $120.23 / $316.23
| Professional | | $81.28 | $120.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $109.65 / $177.83
| Professional | | $83.18 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $239.88
| Professional | | $123.03 | $162.18 | $239.88 |
- 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
- $100.00 / $147.91 / $223.87
| Professional | | $100.00 | $147.91 | $223.87 |