- 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
- $85.11 / $120.23 / $288.40
| Professional | | $85.11 | $120.23 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $85.11 / $186.21
| Professional | | $64.57 | $85.11 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $114.82 / $177.83
| Professional | | $64.57 | $114.82 | $177.83 |
- 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
- $63.10 / $109.65 / $144.54
| Professional | | $63.10 | $109.65 | $144.54 |