- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.53 / $2,063.73 / $5,324.78
| Facility | | $1,115.53 | $2,063.73 | $5,324.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.53 / $1,175.02 / $1,323.76
| Professional | | $1,115.53 | $1,175.02 | $1,323.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.43 / $1,487.37 / $1,487.37
| Professional | | $773.43 | $1,487.37 | $1,487.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.56 / $2,951.83 / $4,664.04
| Facility | | $64.56 | $2,951.83 | $4,664.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.10 / $870.11 / $2,265.83
| Professional | | $35.10 | $870.11 | $2,265.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,588.02 / $7,065.01 / $7,065.01
| Facility | | $2,588.02 | $7,065.01 | $7,065.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $892.42 / $1,487.37
| Professional | | $624.70 | $892.42 | $1,487.37 |