- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $173.78 / $213.80
| Professional | | $112.20 | $173.78 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $3,162.28 / $6,606.93
| Facility | | $478.63 | $3,162.28 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $302.00 / $416.87
| Professional | | $251.19 | $302.00 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $562.34
| Professional | | $251.19 | $346.74 | $562.34 |