- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,890.45 / $10,232.93
| Facility | | $707.95 | $3,890.45 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,000.00 / $2,238.72
| Professional | | $208.93 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $6,025.60 / $13,803.84
| Facility | | $2,089.30 | $6,025.60 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,096.48 / $2,754.23
| Professional | | $234.42 | $1,096.48 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $3,090.30 / $9,549.93
| Facility | | $213.80 | $3,090.30 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $812.83 / $3,019.95
| Professional | | $245.47 | $812.83 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,202.26 / $3,630.78
| Facility | | $295.12 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $977.24 / $2,398.83
| Professional | | $213.80 | $977.24 | $2,398.83 |