- 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
- $126.65 / $139.25 / $153.47
| Professional | | $126.65 | $139.25 | $153.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.38 / $152.21 / $267.91
| Professional | | $129.38 | $152.21 | $267.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.82 / $200.55 / $261.76
| Professional | | $125.82 | $200.55 | $261.76 |
- 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
- $131.81 / $180.79 / $264.29
| Professional | | $131.81 | $180.79 | $264.29 |