- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,265.80 / $10,715.19
| Facility | | $891.25 | $4,265.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $588.84 / $1,621.81
| Professional | | $467.74 | $588.84 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $6,025.60 / $12,302.69
| Facility | | $2,041.74 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $1,258.93
| Professional | | $457.09 | $660.69 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $4,073.80
| Facility | | $891.25 | $1,698.24 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,698.24
| Professional | | $501.19 | $758.58 | $1,698.24 |
- 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
- $426.58 / $602.56 / $1,122.02
| Professional | | $426.58 | $602.56 | $1,122.02 |