- 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
- $275.42 / $346.74 / $954.99
| Professional | | $275.42 | $346.74 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $575.44
| Professional | | $288.40 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $676.08
| Professional | | $323.59 | $467.74 | $676.08 |
- 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
- $263.03 / $389.05 / $707.95
| Professional | | $263.03 | $389.05 | $707.95 |