- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,344.23 / $4,897.79
| Facility | | $912.01 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,380.38
| Professional | | $707.95 | $812.83 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $18,620.87 / $26,302.68
| Facility | | $9,549.93 | $18,620.87 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,548.82
| Professional | | $758.58 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $812.83 / $912.01
| Facility | | $776.25 | $812.83 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,778.28
| Professional | | $812.83 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,445.44
| Professional | | $724.44 | $912.01 | $1,445.44 |