- 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
- $141.25 / $239.88 / $501.19
| Professional | | $141.25 | $239.88 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $263.03 / $416.87
| Professional | | $144.54 | $263.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $323.59 / $478.63
| Professional | | $190.55 | $323.59 | $478.63 |
- 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
- $154.88 / $257.04 / $524.81
| Professional | | $154.88 | $257.04 | $524.81 |