- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $4,365.16 / $5,623.41
| Facility | | $380.19 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $380.19 / $794.33
| Professional | | $346.74 | $380.19 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,862.09
| Professional | | $1,071.52 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $588.84 / $8,709.64
| Facility | | $489.78 | $588.84 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $3,715.35
| Professional | | $724.44 | $1,445.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,862.09
| Professional | | $1,071.52 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $954.99 / $2,238.72
| Professional | | $426.58 | $954.99 | $2,238.72 |