- 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
- $56.23 / $125.89 / $407.38
| Professional | | $56.23 | $125.89 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $109.65 / $213.80
| Professional | | $58.88 | $109.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $151.36 / $295.12
| Professional | | $77.62 | $151.36 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $123.03 / $239.88
| Professional | | $64.57 | $123.03 | $239.88 |