- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $4,073.80 / $7,762.47
| Facility | | $776.25 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,995.26
| Professional | | $630.96 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,819.70 / $5,370.32
| Professional | | $741.31 | $1,819.70 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $2,089.30
| Professional | | $758.58 | $1,000.00 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $1,737.80
| Professional | | $724.44 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,803.84 / $26,302.68
| Facility | | $2,344.23 | $13,803.84 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $2,089.30
| Professional | | $588.84 | $1,000.00 | $2,089.30 |