- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $3,162.28 / $8,511.38
| Facility | | $537.03 | $3,162.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $524.81 / $1,548.82
| Professional | | $338.84 | $524.81 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $6,025.60 / $12,302.69
| Facility | | $1,862.09 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $933.25
| Professional | | $331.13 | $478.63 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,548.82 / $3,715.35
| Facility | | $616.60 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $602.56 / $1,288.25
| Professional | | $380.19 | $602.56 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,309.57
| Facility | | $1,000.00 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $489.78 / $933.25
| Professional | | $331.13 | $489.78 | $933.25 |