- 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
- $46.77 / $107.15 / $263.03
| Professional | | $46.77 | $107.15 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $89.13 / $169.82
| Professional | | $47.86 | $89.13 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $97.72 / $158.49
| Professional | | $45.71 | $97.72 | $158.49 |