- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,388.44 / $9,549.93
| Facility | | $741.31 | $3,388.44 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,258.93 / $2,454.71
| Professional | | $363.08 | $1,258.93 | $2,454.71 |
- 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
- $380.19 / $1,445.44 / $3,235.94
| Professional | | $380.19 | $1,445.44 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $2,187.76 / $10,232.93
| Facility | | $363.08 | $2,187.76 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,122.02 / $3,162.28
| Professional | | $398.11 | $1,122.02 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,495.41 / $12,302.69
| Facility | | $1,862.09 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,258.93 / $2,884.03
| Professional | | $380.19 | $1,258.93 | $2,884.03 |