- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $4,365.16 / $10,964.78
| Facility | | $870.96 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $512.86 / $1,202.26
| Professional | | $416.87 | $512.86 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $9,120.11 / $25,118.86
| Facility | | $3,715.35 | $9,120.11 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $630.96 / $1,174.90
| Professional | | $416.87 | $630.96 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,737.80 / $4,365.16
| Facility | | $776.25 | $1,737.80 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $724.44 / $1,584.89
| Professional | | $457.09 | $724.44 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $16,982.44
| Facility | | $2,511.89 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $588.84 / $1,096.48
| Professional | | $416.87 | $588.84 | $1,096.48 |