- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.92 / $2,144.90 / $2,275.58
| Professional | | $1,187.92 | $2,144.90 | $2,275.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,578.10 / $9,477.82 / $297,860.93
| Facility | | $6,578.10 | $9,477.82 | $297,860.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,807.00 / $14,511.00 / $74,646.00
| Facility | | $6,807.00 | $14,511.00 | $74,646.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.84 / $1,999.00 / $3,298.24
| Professional | | $1,368.84 | $1,999.00 | $3,298.24 |