- 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
- $188.40 / $432.65 / $673.87
| Professional | | $188.40 | $432.65 | $673.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.37 / $478.64 / $702.75
| Professional | | $210.37 | $478.64 | $702.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.23 / $435.47 / $989.78
| Professional | | $288.23 | $435.47 | $989.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.28 / $617.33 / $977.45
| Professional | | $346.28 | $617.33 | $977.45 |