- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,630.78 / $9,332.54
| Facility | | $602.56 | $3,630.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $2,454.71 / $5,248.07
| Professional | | $218.78 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,456.54 / $14,125.38
| Facility | | $3,019.95 | $6,456.54 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $2,511.89 / $5,495.41
| Professional | | $234.42 | $2,511.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $7,413.10 / $21,379.62
| Facility | | $269.15 | $7,413.10 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $2,290.87 / $7,244.36
| Professional | | $275.42 | $2,290.87 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,218.10
| Facility | | $2,454.71 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $2,089.30 / $6,165.95
| Professional | | $245.47 | $2,089.30 | $6,165.95 |