- 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
- $161.82 / $209.14 / $412.82
| Professional | | $161.82 | $209.14 | $412.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.88 / $266.92 / $405.33
| Professional | | $226.88 | $266.92 | $405.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.32 / $328.32 / $470.97
| Professional | | $167.32 | $328.32 | $470.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.65 / $328.35 / $449.86
| Professional | | $213.65 | $328.35 | $449.86 |