- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,073.80 / $7,762.47
| Facility | | $851.14 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $870.96 / $2,511.89
| Professional | | $812.83 | $870.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,949.84 / $7,943.28
| Professional | | $851.14 | $1,949.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $2,290.87
| Professional | | $812.83 | $1,047.13 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $776.25 / $1,778.28
| Professional | | $741.31 | $776.25 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $27,542.29
| Facility | | $3,311.31 | $16,218.10 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,949.84
| Professional | | $707.95 | $1,000.00 | $1,949.84 |