- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,148.15
| Professional | | $562.34 | $741.31 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $6,456.54
| Facility | | $4,073.80 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $870.96 / $1,047.13
| Professional | | $616.60 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,096.48
| Professional | | $467.74 | $758.58 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,388.44
| Facility | | $645.65 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $645.65 / $1,000.00
| Professional | | $457.09 | $645.65 | $1,000.00 |