- 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
- $118.33 / $205.65 / $237.68
| Professional | | $118.33 | $205.65 | $237.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.52 / $215.91 / $354.61
| Professional | | $183.52 | $215.91 | $354.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.37 / $251.40 / $384.47
| Professional | | $169.37 | $251.40 | $384.47 |
- 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
- $205.33 / $241.80 / $370.90
| Professional | | $205.33 | $241.80 | $370.90 |