- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,137.96 / $7,762.47
| Facility | | $912.01 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $912.01 / $2,290.87
| Professional | | $870.96 | $912.01 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,000.00 / $1,288.25
| Professional | | $977.24 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $2,290.87
| Professional | | $812.83 | $1,122.02 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,819.70 / $2,041.74
| Professional | | $933.25 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $2,290.87
| Professional | | $758.58 | $1,148.15 | $2,290.87 |