- 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
- $84.07 / $238.87 / $345.35
| Professional | | $84.07 | $238.87 | $345.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.24 / $1,762.31 / $2,012.55
| Facility | | $1,277.24 | $1,762.31 | $2,012.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.13 / $210.57 / $210.57
| Professional | | $152.13 | $210.57 | $210.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.67 / $252.68 / $432.24
| Professional | | $166.67 | $252.68 | $432.24 |