- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $925.91 / $6,012.00 / $10,692.00
| Facility | | $925.91 | $6,012.00 | $10,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.27 / $965.66 / $1,591.74
| Professional | | $830.27 | $965.66 | $1,591.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.06 / $1,427.83 / $3,006.14
| Professional | | $837.06 | $1,427.83 | $3,006.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.76 / $1,454.80 / $1,731.71
| Professional | | $1,070.76 | $1,454.80 | $1,731.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,587.62 / $8,385.14 / $15,991.30
| Facility | | $7,587.62 | $8,385.14 | $15,991.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.56 / $986.84 / $1,911.27
| Professional | | $769.56 | $986.84 | $1,911.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,378.00 / $8,305.00 / $14,121.00
| Facility | | $5,378.00 | $8,305.00 | $14,121.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.33 / $1,061.43 / $2,139.21
| Professional | | $647.33 | $1,061.43 | $2,139.21 |