- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $10,964.78
| Facility | | $3,311.31 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $186.21 / $3,548.13
| Professional | | $134.90 | $186.21 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $10,471.29 / $25,703.96
| Facility | | $134.90 | $10,471.29 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $199.53 / $389.05
| Professional | | $144.54 | $199.53 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $186.21 / $371.54
| Professional | | $95.50 | $186.21 | $371.54 |