- 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
- $86.54 / $118.48 / $159.22
| Professional | | $86.54 | $118.48 | $159.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.35 / $141.93 / $193.75
| Professional | | $99.35 | $141.93 | $193.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.51 / $167.11 / $243.70
| Professional | | $101.51 | $167.11 | $243.70 |
- 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
- $93.75 / $168.93 / $268.60
| Professional | | $93.75 | $168.93 | $268.60 |