- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $1,000.00
| Professional | | $239.88 | $371.54 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $389.05
| Professional | | $354.81 | $354.81 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $2,041.74 / $4,897.79
| Facility | | $478.63 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $467.74 / $724.44
| Professional | | $354.81 | $467.74 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,202.26 / $2,041.74
| Facility | | $416.87 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $501.19 / $616.60
| Professional | | $363.08 | $501.19 | $616.60 |