- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,630.78 / $9,549.93
| Facility | | $741.31 | $3,630.78 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $512.86 / $1,819.70
| Professional | | $380.19 | $512.86 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,964.78
| Facility | | $2,089.30 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $588.84 / $1,096.48
| Professional | | $380.19 | $588.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,380.38 / $3,311.31
| Facility | | $776.25 | $1,380.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $660.69 / $1,445.44
| Professional | | $436.52 | $660.69 | $1,445.44 |
- 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
- $371.54 / $512.86 / $977.24
| Professional | | $371.54 | $512.86 | $977.24 |