- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $7,079.46 / $14,125.38
| Facility | | $891.25 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $457.09 / $1,230.27
| Professional | | $275.42 | $457.09 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $1,905.46
| Professional | | $741.31 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $660.69 / $2,089.30
| Facility | | $331.13 | $660.69 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,318.26 / $2,089.30
| Professional | | $691.83 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,659.59 / $2,454.71
| Professional | | $1,047.13 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $575.44 / $2,089.30
| Facility | | $338.84 | $575.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $602.56 / $1,096.48
| Professional | | $60.26 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,380.38 / $2,344.23
| Professional | | $426.58 | $1,380.38 | $2,344.23 |