- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.60 / $1,479.60 / $5,891.47
| Facility | | $1,479.60 | $1,479.60 | $5,891.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,304.10 / $3,304.10 / $3,304.10
| Professional | | $3,304.10 | $3,304.10 | $3,304.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.00 / $561.00 / $842.00
| Professional | | $439.00 | $561.00 | $842.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.81 / $395.25 / $594.64
| Professional | | $287.81 | $395.25 | $594.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.35 / $626.94 / $1,007.17
| Professional | | $372.35 | $626.94 | $1,007.17 |