- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,570.88 / $11,481.54
| Facility | | $851.14 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,513.56
| Professional | | $575.44 | $691.83 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $10,471.29 / $19,498.45
| Facility | | $3,801.89 | $10,471.29 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $870.96 / $1,584.89
| Professional | | $602.56 | $870.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,659.59 / $4,786.30
| Facility | | $398.11 | $1,659.59 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $2,137.96
| Professional | | $630.96 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $9,549.93
| Facility | | $1,288.25 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,479.11
| Professional | | $575.44 | $812.83 | $1,479.11 |