- 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
- $147.91 / $257.04 / $537.03
| Professional | | $147.91 | $257.04 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $281.84 / $501.19
| Professional | | $158.49 | $281.84 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $281.84 / $512.86
| Professional | | $208.93 | $281.84 | $512.86 |
- 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
- $162.18 / $257.04 / $562.34
| Professional | | $162.18 | $257.04 | $562.34 |