- 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
- $163.06 / $195.18 / $275.08
| Professional | | $163.06 | $195.18 | $275.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.12 / $239.56 / $354.43
| Professional | | $175.12 | $239.56 | $354.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.33 / $306.55 / $385.17
| Professional | | $221.33 | $306.55 | $385.17 |
- 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
- $153.60 / $265.48 / $410.52
| Professional | | $153.60 | $265.48 | $410.52 |