- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,630.27 / $6,606.93
| Facility | | $1,096.48 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,445.44
| Professional | | $776.25 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $1,584.89
| Professional | | $933.25 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,466.84 / $13,489.63
| Facility | | $1,023.29 | $4,466.84 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,071.52 / $6,309.57
| Professional | | $776.25 | $1,071.52 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,762.47 / $14,125.38
| Facility | | $1,949.84 | $7,762.47 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,479.11
| Professional | | $741.31 | $1,000.00 | $1,479.11 |