- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,467.37 / $9,332.54
| Facility | | $812.83 | $3,467.37 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,445.44
| Professional | | $707.95 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $977.24 / $7,079.46
| Facility | | $660.69 | $977.24 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,137.96 / $8,317.64
| Professional | | $933.25 | $2,137.96 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,047.13 / $1,047.13
| Professional | | $1,000.00 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,584.89
| Professional | | $1,047.13 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,737.80
| Facility | | $707.95 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $501.19 / $1,737.80
| Professional | | $407.38 | $501.19 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,047.13 / $1,047.13
| Professional | | $467.74 | $1,047.13 | $1,047.13 |