- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $4,073.80 / $6,456.54
| Facility | | $812.83 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $831.76 / $2,344.23
| Professional | | $794.33 | $831.76 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $2,818.38
| Professional | | $537.03 | $812.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $2,187.76
| Professional | | $794.33 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $758.58 / $1,698.24
| Professional | | $724.44 | $758.58 | $1,698.24 |
- 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
- $676.08 / $1,000.00 / $1,905.46
| Professional | | $676.08 | $1,000.00 | $1,905.46 |