- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $204.17 / $537.03
| Professional | | $169.82 | $204.17 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $204.17 / $346.74
| Professional | | $177.83 | $204.17 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $309.03 / $398.11
| Professional | | $213.80 | $309.03 | $398.11 |
- 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
- $169.82 / $263.03 / $436.52
| Professional | | $169.82 | $263.03 | $436.52 |