- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.53 / $3,472.87 / $8,074.63
| Facility | | $957.53 | $3,472.87 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.79 / $903.65 / $1,446.43
| Professional | | $818.79 | $903.65 | $1,446.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,032.66 / $8,683.04 / $13,628.92
| Facility | | $4,032.66 | $8,683.04 | $13,628.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.66 / $1,112.00 / $1,708.30
| Professional | | $830.66 | $1,112.00 | $1,708.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.91 / $957.91 / $1,322.91
| Facility | | $957.91 | $957.91 | $1,322.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.33 / $1,261.31 / $2,011.67
| Professional | | $860.33 | $1,261.31 | $2,011.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,198.00
| Facility | | $1,403.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.86 / $1,163.08 / $1,996.63
| Professional | | $828.86 | $1,163.08 | $1,996.63 |