- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,235.94 / $6,760.83
| Facility | | $741.31 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $776.25 / $2,089.30
| Professional | | $416.87 | $776.25 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $977.24 / $7,079.46
| Facility | | $457.09 | $977.24 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,202.26
| Professional | | $758.58 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $8,511.38
| Facility | | $2,951.21 | $6,025.60 | $8,511.38 |