- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,370.32 / $5,623.41
| Facility | | $4,786.30 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,949.84
| Professional | | $616.60 | $891.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,412.54
| Professional | | $691.83 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,949.84
| Professional | | $794.33 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $1,698.24
| Professional | | $776.25 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,370.32 / $5,623.41
| Facility | | $4,786.30 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $977.24 / $2,454.71
| Professional | | $616.60 | $977.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $1,698.24
| Professional | | $776.25 | $1,096.48 | $1,698.24 |