- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $4,073.80 / $10,964.78
| Facility | | $831.76 | $4,073.80 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $1,202.26 / $2,630.27
| Professional | | $309.03 | $1,202.26 | $2,630.27 |
- 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
- $316.23 / $1,380.38 / $3,388.44
| Professional | | $316.23 | $1,380.38 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $5,011.87 / $13,803.84
| Facility | | $501.19 | $5,011.87 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,174.90 / $3,981.07
| Professional | | $354.81 | $1,174.90 | $3,981.07 |
- 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
- $316.23 / $1,288.25 / $3,090.30
| Professional | | $316.23 | $1,288.25 | $3,090.30 |