- 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
- $205.23 / $290.27 / $511.33
| Professional | | $205.23 | $290.27 | $511.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.30 / $529.13 / $529.13
| Professional | | $430.30 | $529.13 | $529.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $535.37 / $922.72
| Professional | | $300.00 | $535.37 | $922.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.14 / $396.34 / $899.81
| Professional | | $280.14 | $396.34 | $899.81 |