- 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
- $257.04 / $354.81 / $812.83
| Professional | | $257.04 | $354.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $331.13 / $537.03
| Professional | | $269.15 | $331.13 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $630.96
| Professional | | $302.00 | $457.09 | $630.96 |
- 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
- $245.47 / $363.08 / $660.69
| Professional | | $245.47 | $363.08 | $660.69 |