- 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 / $251.19 / $575.44
| Professional | | $177.83 | $251.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $208.93 / $389.05
| Professional | | $177.83 | $208.93 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $323.59 / $426.58
| Professional | | $223.87 | $323.59 | $426.58 |
- 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
- $177.83 / $269.15 / $457.09
| Professional | | $177.83 | $269.15 | $457.09 |