- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,762.47 / $8,317.64
| Facility | | $2,089.30 | $7,762.47 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $4,365.16
| Professional | | $1,513.56 | $2,187.76 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $85.11
| Professional | | $50.12 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $3,981.07
| Facility | | $1,659.59 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,265.80
| Professional | | $3,630.78 | $3,630.78 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $15,135.61 / $56,234.13
| Facility | | $1,023.29 | $15,135.61 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,981.07
| Professional | | $1,513.56 | $2,238.72 | $3,981.07 |