- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $3,235.94 / $6,760.83
| Facility | | $363.08 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $467.74 / $1,513.56
| Professional | | $245.47 | $467.74 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $3,019.95 / $10,000.00
| Facility | | $467.74 | $3,019.95 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $977.24
| Professional | | $524.81 | $602.56 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $10,964.78
| Facility | | $4,897.79 | $8,128.31 | $10,964.78 |