- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,630.78 / $9,549.93
| Facility | | $602.56 | $3,630.78 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $602.56 / $1,412.54
| Professional | | $416.87 | $602.56 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,248.07 / $10,964.78
| Facility | | $1,819.70 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $1,023.29
| Professional | | $354.81 | $524.81 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $2,398.83
| Facility | | $588.84 | $870.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $630.96 / $1,318.26
| Professional | | $398.11 | $630.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,570.40 / $6,025.60
| Facility | | $645.65 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $537.03 / $1,000.00
| Professional | | $371.54 | $537.03 | $1,000.00 |