- 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
- $161.57 / $213.08 / $253.61
| Professional | | $161.57 | $213.08 | $253.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.60 / $233.65 / $392.73
| Professional | | $198.60 | $233.65 | $392.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.50 / $289.47 / $417.70
| Professional | | $202.50 | $289.47 | $417.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.87 / $289.54 / $443.77
| Professional | | $176.87 | $289.54 | $443.77 |