- 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
- $178.60 / $236.48 / $325.05
| Professional | | $178.60 | $236.48 | $325.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.51 / $249.84 / $414.75
| Professional | | $180.51 | $249.84 | $414.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.89 / $325.17 / $427.07
| Professional | | $251.89 | $325.17 | $427.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,257.00 / $6,383.00
| Facility | | $1,649.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.78 / $296.02 / $455.04
| Professional | | $186.78 | $296.02 | $455.04 |