- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,467.37 / $7,943.28
| Facility | | $3,090.30 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $954.99 / $2,238.72
| Professional | | $630.96 | $954.99 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,513.56
| Professional | | $758.58 | $1,122.02 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,089.30
| Professional | | $812.83 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,819.70
| Professional | | $870.96 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,467.37 / $7,943.28
| Facility | | $3,090.30 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,023.29 / $2,344.23
| Professional | | $630.96 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $1,819.70
| Professional | | $812.83 | $1,202.26 | $1,819.70 |