- 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
- $162.18 / $245.47 / $575.44
| Professional | | $162.18 | $245.47 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $199.53 / $346.74
| Professional | | $147.91 | $199.53 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $288.40 / $426.58
| Professional | | $223.87 | $288.40 | $426.58 |
- 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
- $181.97 / $263.03 / $398.11
| Professional | | $181.97 | $263.03 | $398.11 |