- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,265.80
| Professional | | $3,715.35 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $3,388.44
| Professional | | $2,884.03 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,248.07
| Professional | | $3,715.35 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,818.38 / $2,951.21
| Professional | | $125.89 | $2,818.38 | $2,951.21 |