- 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
- $568.96 / $642.51 / $756.47
| Professional | | $568.96 | $642.51 | $756.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.85 / $961.00 / $961.00
| Professional | | $816.85 | $961.00 | $961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $812.82 / $1,164.22
| Professional | | $150.00 | $812.82 | $1,164.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.94 / $960.42 / $1,624.23
| Professional | | $583.94 | $960.42 | $1,624.23 |