- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,754.23 / $4,073.80
| Facility | | $1,412.54 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $1,230.27 / $2,187.76
| Professional | | $57.54 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $1,862.09 / $5,370.32
| Professional | | $43.65 | $1,862.09 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $1,230.27 / $3,235.94
| Professional | | $61.66 | $1,230.27 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $3,019.95
| Professional | | $1,412.54 | $1,659.59 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $26,302.68
| Facility | | $1,023.29 | $4,786.30 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $162.18 / $3,090.30
| Professional | | $53.70 | $162.18 | $3,090.30 |