- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,162.28 / $7,762.47
| Facility | | $758.58 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $512.86 / $758.58
| Professional | | $223.87 | $512.86 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $741.31 / $891.25
| Professional | | $676.08 | $741.31 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $794.33 / $1,698.24
| Professional | | $758.58 | $794.33 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,905.46
| Professional | | $691.83 | $1,000.00 | $1,905.46 |