- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,445.44 / $3,467.37
| Facility | | $346.74 | $1,445.44 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,047.13 / $4,466.84
| Professional | | $389.05 | $1,047.13 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,772.37 / $13,182.57
| Facility | | $8,128.31 | $9,772.37 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,445.44 / $2,754.23
| Professional | | $512.86 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | 53 | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $870.96 / $3,162.28
| Professional | | $389.05 | $870.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,754.40 / $13,803.84
| Facility | | $2,454.71 | $5,754.40 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,288.25 / $2,691.53
| Professional | | $346.74 | $1,288.25 | $2,691.53 |