- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.08 / $1,397.00 / $4,478.00
| Facility | | $755.08 | $1,397.00 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.80 / $755.08 / $898.55
| Professional | | $610.80 | $755.08 | $898.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,027.36 / $3,027.36 / $3,632.83
| Facility | | $3,027.36 | $3,027.36 | $3,632.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.26 / $920.32 / $974.46
| Professional | | $736.26 | $920.32 | $974.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.45 / $2,849.45 / $2,849.45
| Facility | | $2,849.45 | $2,849.45 | $2,849.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.75 / $957.82 / $1,241.80
| Professional | | $615.75 | $957.82 | $1,241.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.91 / $839.19 / $1,296.49
| Professional | | $585.91 | $839.19 | $1,296.49 |