- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.12 / $510.14 / $589.60
| Professional | | $366.12 | $510.14 | $589.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.47 / $482.32 / $763.13
| Professional | | $348.47 | $482.32 | $763.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.42 / $651.63 / $812.94
| Professional | | $502.42 | $651.63 | $812.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.45 / $516.34 / $860.24
| Professional | | $355.45 | $516.34 | $860.24 |