- 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
- $162.10 / $263.66 / $401.44
| Professional | | $162.10 | $263.66 | $401.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.98 / $315.24 / $489.01
| Professional | | $184.98 | $315.24 | $489.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.65 / $349.87 / $552.33
| Professional | | $236.65 | $349.87 | $552.33 |
- 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
- $219.57 / $410.76 / $635.79
| Professional | | $219.57 | $410.76 | $635.79 |