- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $776.25 / $1,479.11
| Professional | | $676.08 | $776.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,748.98 / $15,848.93
| Facility | | $9,772.37 | $11,748.98 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,230.27
| Professional | | $691.83 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,698.24
| Professional | | $616.60 | $891.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,258.93
| Professional | | $562.34 | $741.31 | $1,258.93 |