- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,623.41 / $14,125.38
| Facility | | $1,096.48 | $5,623.41 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $16,218.10
| Professional | | $3,801.89 | $5,128.61 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $4,265.80
| Facility | | $3,162.28 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $4,466.84
| Facility | | $64.57 | $64.57 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |