- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $3,162.28 / $4,570.88
| Facility | | $223.87 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,148.15 / $1,412.54
| Professional | | $223.87 | $1,148.15 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $1,949.84
| Professional | | $1,122.02 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $1,202.26
| Professional | | $602.56 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,513.56 / $1,778.28
| Professional | | $1,445.44 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,041.74
| Professional | | $977.24 | $1,288.25 | $2,041.74 |