- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $9,120.11 / $16,595.87
| Facility | | $794.33 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $891.25 / $1,174.90
| Professional | | $346.74 | $891.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,698.24
| Facility | | $794.33 | $1,000.00 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,949.84
| Professional | | $870.96 | $1,148.15 | $1,949.84 |