- 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
- $173.78 / $309.03 / $645.65
| Professional | | $173.78 | $309.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $323.59 / $512.86
| Professional | | $177.83 | $323.59 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $346.74 / $630.96
| Professional | | $234.42 | $346.74 | $630.96 |
- 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
- $177.83 / $309.03 / $645.65
| Professional | | $177.83 | $309.03 | $645.65 |