- 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
- $123.16 / $217.63 / $387.77
| Professional | | $123.16 | $217.63 | $387.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $261.52 / $388.57
| Professional | | $148.32 | $261.52 | $388.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.47 / $314.83 / $514.83
| Professional | | $201.47 | $314.83 | $514.83 |
- 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
- $180.12 / $356.87 / $508.27
| Professional | | $180.12 | $356.87 | $508.27 |