- 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
- $102.33 / $125.89 / $363.08
| Professional | | $102.33 | $125.89 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $102.33 / $181.97
| Professional | | $77.62 | $102.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $117.49 / $213.80
| Professional | | $83.18 | $117.49 | $213.80 |
- 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
- $75.86 / $123.03 / $177.83
| Professional | | $75.86 | $123.03 | $177.83 |