- 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
- $104.71 / $199.53 / $501.19
| Professional | | $104.71 | $199.53 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $154.88 / $281.84
| Professional | | $128.82 | $154.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $234.42 / $338.84
| Professional | | $165.96 | $234.42 | $338.84 |
- 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 / $229.09 / $354.81
| Professional | | $154.88 | $229.09 | $354.81 |