- 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
- $112.20 / $141.25 / $302.00
| Professional | | $112.20 | $141.25 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $162.18 / $218.78
| Professional | | $104.71 | $162.18 | $218.78 |
- 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
- $123.03 / $162.18 / $239.88
| Professional | | $123.03 | $162.18 | $239.88 |