- 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
- $151.36 / $269.15 / $524.81
| Professional | | $151.36 | $269.15 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $275.42 / $457.09
| Professional | | $151.36 | $275.42 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $338.84 / $512.86
| Professional | | $199.53 | $338.84 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,412.54 / $6,456.54
| Facility | | $338.84 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $275.42 / $524.81
| Professional | | $162.18 | $275.42 | $524.81 |