- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $104.71 / $257.04
| Professional | | $46.77 | $104.71 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $81.28 / $173.78
| Professional | | $42.66 | $81.28 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $104.71 / $245.47
| Professional | | $57.54 | $104.71 | $245.47 |
- 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
- $51.29 / $100.00 / $194.98
| Professional | | $51.29 | $100.00 | $194.98 |