- 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
- $572.82 / $634.58 / $747.39
| Professional | | $572.82 | $634.58 | $747.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.16 / $706.08 / $1,105.93
| Professional | | $600.16 | $706.08 | $1,105.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $773.15 / $1,171.67
| Professional | | $150.00 | $773.15 | $1,171.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.82 / $706.61 / $982.11
| Professional | | $532.82 | $706.61 | $982.11 |