- 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
- $177.83 / $263.03 / $812.83
| Professional | | $177.83 | $263.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $380.19
| Professional | | $177.83 | $234.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $338.84 / $512.86
| Professional | | $263.03 | $338.84 | $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
- $213.80 / $309.03 / $467.74
| Professional | | $213.80 | $309.03 | $467.74 |