- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.15 / $2,077.41 / $3,116.11
| Facility | | $658.15 | $2,077.41 | $3,116.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.92 / $1,499.36 / $2,457.40
| Professional | | $310.92 | $1,499.36 | $2,457.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,304.24 / $5,304.24 / $6,365.09
| Facility | | $5,304.24 | $5,304.24 | $6,365.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.47 / $531.58 / $2,308.00
| Professional | | $361.47 | $531.58 | $2,308.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.29 / $717.59 / $3,239.52
| Professional | | $518.29 | $717.59 | $3,239.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,555.00 / $8,929.00
| Facility | | $2,104.00 | $4,555.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.05 / $2,034.43 / $3,670.00
| Professional | | $1,707.05 | $2,034.43 | $3,670.00 |