- 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
- $135.08 / $254.18 / $255.55
| Professional | | $135.08 | $254.18 | $255.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.18 / $264.92 / $458.57
| Professional | | $225.18 | $264.92 | $458.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.85 / $306.75 / $470.52
| Professional | | $211.85 | $306.75 | $470.52 |
- 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
- $216.92 / $297.54 / $458.50
| Professional | | $216.92 | $297.54 | $458.50 |