- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,158.82 / $3,158.82 / $3,158.82
| Facility | | $3,158.82 | $3,158.82 | $3,158.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $5,707.27
| Professional | | $318.22 | $318.22 | $5,707.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.34 / $56.34 / $56.34
| Professional | | $56.34 | $56.34 | $56.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |