- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,412.54 / $2,041.74
| Facility | | $676.08 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $691.83
| Professional | | $524.81 | $616.60 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,089.30
| Facility | | $1,513.56 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $812.83
| Professional | | $616.60 | $616.60 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $676.08 / $891.25
| Professional | | $398.11 | $676.08 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $4,677.35
| Facility | | $977.24 | $2,041.74 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,000.00
| Professional | | $478.63 | $660.69 | $1,000.00 |