- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,388.44 / $9,772.37
| Facility | | $707.95 | $3,388.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $812.83 / $1,659.59
| Professional | | $199.53 | $812.83 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,413.10 / $15,135.61
| Facility | | $2,884.03 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $891.25 / $2,238.72
| Professional | | $218.78 | $891.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,630.27 / $7,244.36
| Facility | | $34.67 | $2,630.27 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $741.31 / $2,238.72
| Professional | | $229.09 | $741.31 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $12,302.69
| Facility | | $1,819.70 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $870.96 / $2,041.74
| Professional | | $208.93 | $870.96 | $2,041.74 |