- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $9,772.37 / $24,547.09
| Facility | | $1,659.59 | $9,772.37 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $13,803.84
| Professional | | $3,090.30 | $3,890.45 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.51 / $10.00 / $12.59
| Professional | | $8.51 | $10.00 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Facility | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $9,772.37 / $24,547.09
| Facility | | $1,659.59 | $9,772.37 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,890.45 / $9,772.37
| Professional | | $1,047.13 | $3,890.45 | $9,772.37 |