- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $2,454.71
| Facility | | $691.83 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $616.60 / $707.95
| Professional | | $467.74 | $616.60 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,606.93
| Facility | | $4,786.30 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $707.95
| Professional | | $537.03 | $537.03 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $812.83 / $977.24
| Professional | | $398.11 | $812.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $10,964.78
| Facility | | $1,230.27 | $2,951.21 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,000.00
| Professional | | $467.74 | $549.54 | $1,000.00 |