- 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
- $123.03 / $223.87 / $467.74
| Professional | | $123.03 | $223.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $234.42 / $398.11
| Professional | | $131.83 | $234.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $302.00 / $524.81
| Professional | | $173.78 | $302.00 | $524.81 |
- 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
- $138.04 / $239.88 / $489.78
| Professional | | $138.04 | $239.88 | $489.78 |