- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.65 / $1,002.07 / $5,785.27
| Facility | | $801.65 | $1,002.07 | $5,785.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.65 / $935.26 / $1,202.48
| Professional | | $801.65 | $935.26 | $1,202.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.49 / $923.29 / $5,024.00
| Facility | | $659.49 | $923.29 | $5,024.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.23 / $1,627.23 / $1,949.60
| Professional | | $1,627.23 | $1,627.23 | $1,949.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.65 / $801.65 / $1,135.68
| Professional | | $801.65 | $801.65 | $1,135.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,336.09
| Facility | | $1,336.09 | $1,336.09 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.63 / $561.16 / $2,004.14
| Professional | | $467.63 | $561.16 | $2,004.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.65 / $801.65 / $801.65
| Professional | | $801.65 | $801.65 | $801.65 |