- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.87 / $1,277.00 / $3,109.00
| Facility | | $837.87 | $1,277.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.76 / $837.87 / $1,055.54
| Professional | | $626.76 | $837.87 | $1,055.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.24 / $932.80 / $987.67
| Professional | | $746.24 | $932.80 | $987.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.14 / $1,055.58 / $1,306.22
| Professional | | $753.14 | $1,055.58 | $1,306.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.44 / $944.54 / $1,329.64
| Professional | | $650.44 | $944.54 | $1,329.64 |