- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.43 / $3,008.50 / $7,325.50
| Facility | | $984.43 | $3,008.50 | $7,325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.67 / $803.32 / $1,303.52
| Professional | | $704.67 | $803.32 | $1,303.52 |
- 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
- $742.41 / $1,008.59 / $1,588.52
| Professional | | $742.41 | $1,008.59 | $1,588.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $901.69 / $1,574.05 / $1,873.87
| Facility | | $901.69 | $1,574.05 | $1,873.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.56 / $1,136.83 / $1,798.60
| Professional | | $798.56 | $1,136.83 | $1,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,564.50 / $5,391.00 / $9,078.00
| Facility | | $2,564.50 | $5,391.00 | $9,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.62 / $1,044.55 / $1,757.70
| Professional | | $704.62 | $1,044.55 | $1,757.70 |