- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.52 / $3,008.50 / $7,325.50
| Facility | | $906.52 | $3,008.50 | $7,325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.14 / $708.64 / $1,137.91
| Professional | | $622.14 | $708.64 | $1,137.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,302.10 / $5,196.00 / $10,517.23
| Facility | | $3,302.10 | $5,196.00 | $10,517.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.65 / $890.38 / $1,405.03
| Professional | | $653.65 | $890.38 | $1,405.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $842.00 / $1,574.05 / $2,070.38
| Facility | | $842.00 | $1,574.05 | $2,070.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.59 / $1,001.18 / $1,585.24
| Professional | | $705.59 | $1,001.18 | $1,585.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $5,111.00 / $9,202.00
| Facility | | $2,200.00 | $5,111.00 | $9,202.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.65 / $911.75 / $1,545.16
| Professional | | $620.65 | $911.75 | $1,545.16 |