- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $288.40 / $812.83
| Professional | | $245.47 | $288.40 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $275.42 / $478.63
| Professional | | $239.88 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $575.44
| Professional | | $302.00 | $436.52 | $575.44 |
- 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 / $371.54 / $602.56
| Professional | | $245.47 | $371.54 | $602.56 |