- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.86 / $1,397.00 / $4,478.00
| Facility | | $826.86 | $1,397.00 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.35 / $826.86 / $1,173.35
| Professional | | $653.35 | $826.86 | $1,173.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,555.03 / $3,555.03 / $4,266.04
| Facility | | $3,555.03 | $3,555.03 | $4,266.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.93 / $1,195.06 / $1,327.84
| Professional | | $902.93 | $1,195.06 | $1,327.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,708.38 / $2,708.38 / $2,708.38
| Facility | | $2,708.38 | $2,708.38 | $2,708.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.00 / $904.44 / $1,384.67
| Professional | | $518.00 | $904.44 | $1,384.67 |
- 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
- $645.86 / $807.32 / $1,427.65
| Professional | | $645.86 | $807.32 | $1,427.65 |