- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,090.30 / $8,912.51
| Facility | | $616.60 | $3,090.30 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $1,023.29 / $3,090.30
| Professional | | $199.53 | $1,023.29 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,025.60 / $13,489.63
| Facility | | $3,388.44 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $1,819.70 / $4,897.79
| Professional | | $190.55 | $1,819.70 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,570.88 / $12,589.25
| Facility | | $34.67 | $4,570.88 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $954.99 / $4,570.88
| Professional | | $229.09 | $954.99 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,202.26 / $3,715.35
| Facility | | $295.12 | $1,202.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,445.44 / $4,365.16
| Professional | | $204.17 | $1,445.44 | $4,365.16 |