- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $4,570.88 / $11,481.54
| Facility | | $870.96 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,412.54
| Professional | | $512.86 | $676.08 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,025.60 / $13,803.84
| Facility | | $2,290.87 | $6,025.60 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $851.14 / $1,584.89
| Professional | | $562.34 | $851.14 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,398.83 / $11,220.18
| Facility | | $1,047.13 | $2,398.83 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $2,137.96
| Professional | | $616.60 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,623.41 / $12,589.25
| Facility | | $1,995.26 | $5,623.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,548.82
| Professional | | $524.81 | $812.83 | $1,548.82 |