- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $5,248.07 / $13,489.63
| Facility | | $831.76 | $5,248.07 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $660.69 / $1,412.54
| Professional | | $467.74 | $660.69 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,606.93 / $14,454.40
| Facility | | $3,235.94 | $6,606.93 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $691.83 / $1,288.25
| Professional | | $457.09 | $691.83 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,778.28 / $4,897.79
| Facility | | $691.83 | $1,778.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $831.76 / $1,778.28
| Professional | | $524.81 | $831.76 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $10,964.78
| Facility | | $1,513.56 | $4,570.88 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $691.83 / $1,288.25
| Professional | | $457.09 | $691.83 | $1,288.25 |