- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.39 / $374.89 / $513.42
| Professional | | $286.39 | $374.89 | $513.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.05 / $475.79 / $674.23
| Professional | | $333.05 | $475.79 | $674.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.31 / $518.45 / $952.10
| Professional | | $370.31 | $518.45 | $952.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $587.78 / $918.37
| Professional | | $345.40 | $587.78 | $918.37 |