- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $323.59 / $660.69
| Professional | | $251.19 | $323.59 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $275.42 / $478.63
| Professional | | $204.17 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $316.23 / $562.34
| Professional | | $204.17 | $316.23 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $6,025.60
| Facility | | $1,348.96 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $316.23 / $478.63
| Professional | | $208.93 | $316.23 | $478.63 |