- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $302.00 / $794.33
| Professional | | $213.80 | $302.00 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $263.03 / $426.58
| Professional | | $213.80 | $263.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $512.86
| Professional | | $239.88 | $371.54 | $512.86 |
- 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
- $204.17 / $295.12 / $524.81
| Professional | | $204.17 | $295.12 | $524.81 |