- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,073.80 / $10,715.19
| Facility | | $891.25 | $4,073.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,230.27 / $2,187.76
| Professional | | $338.84 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,511.38 / $16,218.10
| Facility | | $3,311.31 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,202.26 / $3,630.78
| Professional | | $371.54 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,890.45 / $11,220.18
| Facility | | $524.81 | $3,890.45 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,202.26 / $3,548.13
| Professional | | $416.87 | $1,202.26 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,495.41 / $12,302.69
| Facility | | $1,905.46 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,174.90 / $2,951.21
| Professional | | $371.54 | $1,174.90 | $2,951.21 |