- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,471.29
| Facility | | $2,089.30 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $186.21 / $295.12
| Professional | | $151.36 | $186.21 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $1,000.00 / $3,311.31
| Facility | | $162.18 | $1,000.00 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $245.47 / $1,412.54
| Professional | | $186.21 | $245.47 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $3,311.31
| Facility | | $812.83 | $1,202.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $234.42 / $316.23
| Professional | | $194.98 | $234.42 | $316.23 |