- 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
- $281.12 / $376.02 / $477.02
| Professional | | $281.12 | $376.02 | $477.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.29 / $384.40 / $614.34
| Professional | | $299.29 | $384.40 | $614.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.04 / $503.77 / $663.00
| Professional | | $373.04 | $503.77 | $663.00 |
- 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
- $239.31 / $466.48 / $721.27
| Professional | | $239.31 | $466.48 | $721.27 |