- 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
- $260.30 / $352.21 / $389.84
| Professional | | $260.30 | $352.21 | $389.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.02 / $390.61 / $688.53
| Professional | | $332.02 | $390.61 | $688.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $441.38 / $706.91
| Professional | | $300.00 | $441.38 | $706.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.83 / $486.52 / $748.04
| Professional | | $321.83 | $486.52 | $748.04 |