- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $4,897.79 / $5,623.41
| Facility | | $831.76 | $4,897.79 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $1,000.00
| Professional | | $239.88 | $363.08 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $5,623.41
| Facility | | $2,951.21 | $2,951.21 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $4,677.35
| Professional | | $2,290.87 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $5,495.41 / $43,651.58
| Facility | | $338.84 | $5,495.41 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $3,890.45
| Professional | | $1,819.70 | $3,311.31 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,238.72 / $7,413.10
| Facility | | $933.25 | $2,238.72 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $707.95
| Professional | | $316.23 | $416.87 | $707.95 |