- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $6,025.60
| Facility | | $3,162.28 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $3,162.28
| Professional | | $1,148.15 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,128.61 / $12,022.64
| Facility | | $4,365.16 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,344.23 / $2,818.38
| Professional | | $1,071.52 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.20 / $1.20 / $1.20
| Professional | | $1.20 | $1.20 | $1.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,290.87
| Professional | | $1,862.09 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,128.61 / $7,079.46
| Facility | | $1,995.26 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $3,467.37
| Professional | | $1,348.96 | $2,187.76 | $3,467.37 |