- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,513.56 / $2,454.71
| Facility | | $645.65 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $758.58
| Professional | | $478.63 | $537.03 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $741.31
| Professional | | $562.34 | $562.34 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $776.25 / $870.96
| Professional | | $436.52 | $776.25 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $8,317.64
| Facility | | $977.24 | $2,137.96 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $588.84 / $1,000.00
| Professional | | $457.09 | $588.84 | $1,000.00 |