- 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
- $84.00 / $84.00 / $102.23
| Professional | | $84.00 | $84.00 | $102.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,387.61 / $8,286.60 / $10,056.70
| Facility | | $5,387.61 | $8,286.60 | $10,056.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.85 / $213.44 / $363.07
| Professional | | $156.85 | $213.44 | $363.07 |