- 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
- $162.18 / $281.84 / $537.03
| Professional | | $162.18 | $281.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $275.42 / $478.63
| Professional | | $162.18 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $338.84 / $549.54
| Professional | | $213.80 | $338.84 | $549.54 |
- 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
- $169.82 / $269.15 / $562.34
| Professional | | $169.82 | $269.15 | $562.34 |