- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,073.80 / $7,762.47
| Facility | | $977.24 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,000.00 / $2,884.03
| Professional | | $954.99 | $1,000.00 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,818.38 / $6,456.54
| Professional | | $794.33 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $2,630.27
| Professional | | $954.99 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $912.01 / $2,089.30
| Professional | | $870.96 | $912.01 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,754.40 / $26,302.68
| Facility | | $1,445.44 | $5,754.40 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,290.87
| Professional | | $812.83 | $1,148.15 | $2,290.87 |