- 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
- $250.40 / $315.45 / $456.03
| Professional | | $250.40 | $315.45 | $456.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $358.75 / $581.92
| Professional | | $280.01 | $358.75 | $581.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.65 / $475.93 / $625.75
| Professional | | $343.65 | $475.93 | $625.75 |
- 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
- $250.93 / $437.45 / $676.82
| Professional | | $250.93 | $437.45 | $676.82 |