- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.06 / $380.92 / $605.91
| Professional | | $320.06 | $380.92 | $605.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.07 / $420.86 / $776.44
| Professional | | $304.07 | $420.86 | $776.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.86 / $706.76 / $742.11
| Professional | | $420.86 | $706.76 | $742.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $13,831.00 / $44,924.00
| Facility | | $4,505.00 | $13,831.00 | $44,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.85 / $524.57 / $807.16
| Professional | | $327.85 | $524.57 | $807.16 |