- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,888.44 / $10,964.78
| Facility | | $2,754.23 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $1,412.54 / $3,467.37
| Professional | | $173.78 | $1,412.54 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $616.60 / $4,677.35
| Professional | | $199.53 | $616.60 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $2,137.96 / $3,388.44
| Professional | | $295.12 | $2,137.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $1,778.28 / $3,801.89
| Professional | | $141.25 | $1,778.28 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,884.03 / $7,762.47
| Facility | | $1,412.54 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $1,096.48 / $3,467.37
| Professional | | $141.25 | $1,096.48 | $3,467.37 |