- 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
- $163.51 / $233.42 / $320.77
| Professional | | $163.51 | $233.42 | $320.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.07 / $231.23 / $404.42
| Professional | | $167.07 | $231.23 | $404.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.98 / $313.36 / $393.66
| Professional | | $232.98 | $313.36 | $393.66 |
- 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
- $169.48 / $272.86 / $426.61
| Professional | | $169.48 | $272.86 | $426.61 |