- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,715.35 / $9,549.93
| Facility | | $794.33 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $1,230.27 / $3,388.44
| Professional | | $213.80 | $1,230.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,456.54 / $12,589.25
| Facility | | $2,691.53 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,479.11 / $3,890.45
| Professional | | $257.04 | $1,479.11 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $7,244.36 / $21,379.62
| Facility | | $346.74 | $7,244.36 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,584.89 / $5,495.41
| Professional | | $257.04 | $1,584.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $6,456.54
| Facility | | $1,023.29 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,318.26 / $3,630.78
| Professional | | $223.87 | $1,318.26 | $3,630.78 |