- 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
- $127.94 / $171.47 / $267.91
| Professional | | $127.94 | $171.47 | $267.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.68 / $234.23 / $371.16
| Professional | | $160.68 | $234.23 | $371.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.35 / $243.93 / $407.09
| Professional | | $144.35 | $243.93 | $407.09 |
- 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
- $179.84 / $282.17 / $409.00
| Professional | | $179.84 | $282.17 | $409.00 |