- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.15 / $3,606.50 / $8,074.63
| Facility | | $987.15 | $3,606.50 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.18 / $980.13 / $1,378.34
| Professional | | $811.18 | $980.13 | $1,378.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.47 / $8,883.46 / $15,216.00
| Facility | | $4,586.47 | $8,883.46 | $15,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.55 / $1,159.00 / $1,676.97
| Professional | | $835.55 | $1,159.00 | $1,676.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $972.69 / $972.69 / $2,515.61
| Facility | | $972.69 | $972.69 | $2,515.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.18 / $1,253.60 / $2,106.79
| Professional | | $915.18 | $1,253.60 | $2,106.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.00 / $3,236.00 / $6,792.00
| Facility | | $1,360.00 | $3,236.00 | $6,792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.52 / $1,245.34 / $2,125.23
| Professional | | $860.52 | $1,245.34 | $2,125.23 |