- 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 / $1,047.13
| Professional | | $323.59 | $407.38 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $416.87 / $691.83
| Professional | | $331.13 | $416.87 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $776.25
| Professional | | $380.19 | $537.03 | $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
- $309.03 / $457.09 / $812.83
| Professional | | $309.03 | $457.09 | $812.83 |