- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $2,041.74
| Facility | | $831.76 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $741.31 / $1,047.13
| Professional | | $645.65 | $741.31 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $9,120.11
| Facility | | $6,760.83 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,000.00
| Professional | | $758.58 | $758.58 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,023.29 / $1,202.26
| Professional | | $602.56 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $9,549.93
| Facility | | $977.24 | $2,137.96 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $812.83 / $1,348.96
| Professional | | $630.96 | $812.83 | $1,348.96 |