- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,047.13
| Professional | | $602.56 | $776.25 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $22,908.68 / $40,738.03
| Facility | | $13,182.57 | $22,908.68 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,148.15
| Professional | | $758.58 | $891.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $16,982.44 / $16,982.44
| Facility | | $39.81 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $851.14 / $1,122.02
| Professional | | $489.78 | $851.14 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $12,882.50 / $31,622.78
| Facility | | $1,202.26 | $12,882.50 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $1,202.26
| Professional | | $588.84 | $758.58 | $1,202.26 |