- 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
- $218.78 / $302.00 / $812.83
| Professional | | $218.78 | $302.00 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $295.12 / $436.52
| Professional | | $199.53 | $295.12 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $436.52 / $776.25
| Professional | | $269.15 | $436.52 | $776.25 |
- 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
- $223.87 / $354.81 / $630.96
| Professional | | $223.87 | $354.81 | $630.96 |