- 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
- $152.50 / $286.52 / $286.66
| Professional | | $152.50 | $286.52 | $286.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.58 / $299.51 / $576.33
| Professional | | $254.58 | $299.51 | $576.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.82 / $347.45 / $529.19
| Professional | | $236.82 | $347.45 | $529.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $334.57 / $515.75
| Professional | | $244.82 | $334.57 | $515.75 |