- 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
- $69.18 / $162.18 / $416.87
| Professional | | $69.18 | $162.18 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $114.82 / $165.96
| Professional | | $69.18 | $114.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $151.36 / $263.03
| Professional | | $93.33 | $151.36 | $263.03 |
- 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
- $69.18 / $117.49 / $234.42
| Professional | | $69.18 | $117.49 | $234.42 |