- 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
- $323.59 / $407.38 / $1,148.15
| Professional | | $323.59 | $407.38 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $380.19 / $630.96
| Professional | | $281.84 | $380.19 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $977.24
| Professional | | $389.05 | $562.34 | $977.24 |
- 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
- $302.00 / $524.81 / $870.96
| Professional | | $302.00 | $524.81 | $870.96 |