- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $881.61 / $1,937.18 / $5,510.05
| Facility | | $881.61 | $1,937.18 | $5,510.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.01 / $551.01 / $637.59
| Professional | | $551.01 | $551.01 | $637.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.85 / $1,438.91 / $3,069.89
| Facility | | $1,294.85 | $1,438.91 | $3,069.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.86 / $511.64 / $540.00
| Professional | | $314.86 | $511.64 | $540.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.36 / $2,877.67 / $3,453.13
| Facility | | $1,421.36 | $2,877.67 | $3,453.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.15 / $1,068.32 / $2,429.54
| Professional | | $787.15 | $1,068.32 | $2,429.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.60 / $472.29 / $472.29
| Professional | | $330.60 | $472.29 | $472.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |