- 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
- $166.89 / $285.62 / $457.02
| Professional | | $166.89 | $285.62 | $457.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.37 / $323.27 / $535.26
| Professional | | $202.37 | $323.27 | $535.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.52 / $370.73 / $624.09
| Professional | | $242.52 | $370.73 | $624.09 |
- 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
- $230.79 / $470.28 / $668.55
| Professional | | $230.79 | $470.28 | $668.55 |