- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,786.30 / $10,000.00
| Facility | | $1,584.89 | $4,786.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $1,047.13 / $8,912.51
| Professional | | $218.78 | $1,047.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $12,589.25
| Facility | | $2,454.71 | $3,467.37 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,691.53
| Facility | | $676.08 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |