- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $9,772.37
| Facility | | $812.83 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,513.56 / $3,715.35
| Professional | | $371.54 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $6,456.54 / $12,589.25
| Facility | | $2,089.30 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,584.89 / $3,801.89
| Professional | | $380.19 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $5,128.61 / $15,135.61
| Facility | | $602.56 | $5,128.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,584.89 / $4,365.16
| Professional | | $426.58 | $1,584.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,365.16 / $10,471.29
| Facility | | $1,548.82 | $4,365.16 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,412.54 / $3,388.44
| Professional | | $371.54 | $1,412.54 | $3,388.44 |