- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,778.28
| Professional | | $758.58 | $954.99 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $8,709.64 / $11,748.98
| Facility | | $7,413.10 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,348.96
| Professional | | $794.33 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $977.24 / $1,445.44
| Professional | | $457.09 | $977.24 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,370.32
| Facility | | $1,122.02 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,288.25
| Professional | | $602.56 | $831.76 | $1,288.25 |