- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,570.88 / $11,481.54
| Facility | | $977.24 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,659.59
| Professional | | $691.83 | $831.76 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,715.19 / $20,417.38
| Facility | | $3,981.07 | $10,715.19 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,949.84
| Professional | | $691.83 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,949.84 / $5,623.41
| Facility | | $398.11 | $1,949.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $2,511.89
| Professional | | $758.58 | $1,202.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,778.28
| Professional | | $691.83 | $1,000.00 | $1,778.28 |