- 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
- $129.37 / $220.27 / $398.56
| Professional | | $129.37 | $220.27 | $398.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.26 / $290.43 / $420.74
| Professional | | $145.26 | $290.43 | $420.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.64 / $296.88 / $624.00
| Professional | | $187.64 | $296.88 | $624.00 |
- 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
- $240.14 / $362.26 / $573.14
| Professional | | $240.14 | $362.26 | $573.14 |