- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $14,125.38
| Facility | | $6,456.54 | $7,585.78 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $676.08 / $2,691.53
| Professional | | $478.63 | $676.08 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $2,570.40
| Professional | | $1,659.59 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,621.81
| Professional | | $537.03 | $870.96 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $14,125.38
| Facility | | $3,019.95 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,737.80
| Professional | | $537.03 | $870.96 | $1,737.80 |