- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,715.35 / $10,471.29
| Facility | | $602.56 | $3,715.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $1,047.13
| Professional | | $331.13 | $512.86 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,244.36 / $14,791.08
| Facility | | $2,818.38 | $7,244.36 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $524.81 / $977.24
| Professional | | $281.84 | $524.81 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,862.09 / $4,897.79
| Facility | | $630.96 | $1,862.09 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $630.96 / $1,412.54
| Professional | | $389.05 | $630.96 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,677.35 / $11,220.18
| Facility | | $1,513.56 | $4,677.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $524.81 / $1,000.00
| Professional | | $331.13 | $524.81 | $1,000.00 |