- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.66 / $1,520.00 / $2,250.00
| Facility | | $865.66 | $1,520.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.22 / $649.61 / $1,242.46
| Professional | | $425.22 | $649.61 | $1,242.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.00 / $2,674.66 / $3,598.28
| Facility | | $2,204.00 | $2,674.66 | $3,598.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.15 / $955.57 / $1,169.30
| Professional | | $634.15 | $955.57 | $1,169.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.41 / $545.10 / $1,742.07
| Professional | | $377.41 | $545.10 | $1,742.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.00 / $2,891.00 / $4,402.00
| Facility | | $834.00 | $2,891.00 | $4,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.52 / $606.84 / $791.23
| Professional | | $494.52 | $606.84 | $791.23 |