- 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
- $245.71 / $352.13 / $419.49
| Professional | | $245.71 | $352.13 | $419.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.91 / $320.98 / $535.21
| Professional | | $231.91 | $320.98 | $535.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.35 / $463.50 / $572.87
| Professional | | $334.35 | $463.50 | $572.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.78 / $397.09 / $607.13
| Professional | | $227.78 | $397.09 | $607.13 |