- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $4,570.88 / $11,220.18
| Facility | | $912.01 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $1,548.82
| Professional | | $602.56 | $724.44 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,912.51 / $16,982.44
| Facility | | $3,388.44 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,659.59
| Professional | | $602.56 | $891.25 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,380.38 / $5,248.07
| Facility | | $398.11 | $1,380.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $2,238.72
| Professional | | $660.69 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $8,511.38 / $17,782.79
| Facility | | $2,884.03 | $8,511.38 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,513.56
| Professional | | $562.34 | $794.33 | $1,513.56 |