- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,388.44 / $9,772.37
| Facility | | $977.24 | $3,388.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $380.19 / $1,000.00
| Professional | | $257.04 | $380.19 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,466.84 / $12,882.50
| Facility | | $2,570.40 | $4,466.84 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $707.95 / $3,162.28
| Professional | | $354.81 | $707.95 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $2,754.23
| Facility | | $602.56 | $977.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $436.52 / $1,412.54
| Professional | | $346.74 | $436.52 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,202.26 / $3,630.78
| Facility | | $269.15 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $812.83
| Professional | | $316.23 | $457.09 | $812.83 |