- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.17 / $455.40 / $560.15
| Professional | | $434.17 | $455.40 | $560.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.48 / $535.86 / $837.78
| Professional | | $455.48 | $535.86 | $837.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $587.78 / $887.54
| Professional | | $300.00 | $587.78 | $887.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.18 / $613.55 / $941.28
| Professional | | $400.18 | $613.55 | $941.28 |