- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $793.02 / $2,731.73 / $5,130.00
| Facility | | $793.02 | $2,731.73 | $5,130.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.42 / $760.05 / $1,062.93
| Professional | | $256.42 | $760.05 | $1,062.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.45 / $408.78 / $1,145.92
| Professional | | $282.45 | $408.78 | $1,145.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,731.37 / $3,257.74 / $13,824.15
| Facility | | $1,731.37 | $3,257.74 | $13,824.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.00 / $792.00 / $792.00
| Professional | | $792.00 | $792.00 | $792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.45 / $1,078.14 / $2,072.09
| Professional | | $794.45 | $1,078.14 | $2,072.09 |