- 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
- $117.76 / $181.83 / $261.48
| Professional | | $117.76 | $181.83 | $261.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.77 / $252.31 / $359.98
| Professional | | $163.77 | $252.31 | $359.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $250.00 / $431.49
| Professional | | $150.00 | $250.00 | $431.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.48 / $269.12 / $442.67
| Professional | | $166.48 | $269.12 | $442.67 |