- 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
- $143.68 / $247.39 / $393.30
| Professional | | $143.68 | $247.39 | $393.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.21 / $308.13 / $508.82
| Professional | | $193.21 | $308.13 | $508.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.92 / $341.27 / $554.96
| Professional | | $257.92 | $341.27 | $554.96 |
- 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
- $235.26 / $439.04 / $656.57
| Professional | | $235.26 | $439.04 | $656.57 |