- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.08 / $391.34 / $538.19
| Professional | | $292.08 | $391.34 | $538.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.84 / $544.88 / $720.84
| Professional | | $399.84 | $544.88 | $720.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.21 / $596.97 / $1,045.61
| Professional | | $403.21 | $596.97 | $1,045.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $3,837.40 / $5,510.00
| Facility | | $1,812.00 | $3,837.40 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.08 / $616.55 / $949.52
| Professional | | $387.08 | $616.55 | $949.52 |