- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.46 / $4,007.27 / $15,127.88
| Facility | | $573.46 | $4,007.27 | $15,127.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $183.50
| Professional | | $176.45 | $176.45 | $183.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.41 / $155.41 / $460.73
| Facility | | $155.41 | $155.41 | $460.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Professional | | $176.45 | $176.45 | $176.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Facility | | $176.45 | $176.45 | $176.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $186.07
| Professional | | $176.45 | $176.45 | $186.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $196.43
| Professional | | $176.45 | $176.45 | $196.43 |