- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $978.12 / $2,709.39 / $4,736.16
| Facility | | $978.12 | $2,709.39 | $4,736.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.25 / $1,042.47 / $1,544.40
| Professional | | $965.25 | $1,042.47 | $1,544.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.36 / $3,706.56 / $5,894.46
| Facility | | $1,360.36 | $3,706.56 | $5,894.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.54 / $540.54 / $1,287.00
| Professional | | $540.54 | $540.54 | $1,287.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.90 / $1,129.33 / $3,312.74
| Facility | | $752.90 | $1,129.33 | $3,312.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.24 / $945.97 / $1,866.15
| Professional | | $598.24 | $945.97 | $1,866.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $978.12 / $1,287.00 / $1,801.80
| Facility | | $978.12 | $1,287.00 | $1,801.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.25 / $1,801.80 / $3,088.80
| Professional | | $965.25 | $1,801.80 | $3,088.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.54 / $540.54 / $952.38
| Professional | | $540.54 | $540.54 | $952.38 |