- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $877.35 / $1,272.16 / $5,615.52
| Facility | | $877.35 | $1,272.16 | $5,615.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.92 / $912.44 / $1,041.11
| Professional | | $777.92 | $912.44 | $1,041.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.71 / $1,461.05 / $2,304.51
| Professional | | $782.71 | $1,461.05 | $2,304.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $668.78 / $3,590.04 / $6,226.96
| Facility | | $668.78 | $3,590.04 | $6,226.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.95 / $1,743.95 / $8,405.84
| Professional | | $1,743.95 | $1,743.95 | $8,405.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.47 / $8,283.76 / $8,283.76
| Facility | | $3,034.47 | $8,283.76 | $8,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,684.87 / $8,684.87 / $13,079.63
| Professional | | $8,684.87 | $8,684.87 | $13,079.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $701.88 / $1,743.95
| Professional | | $491.32 | $701.88 | $1,743.95 |