- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $5,370.32 / $7,943.28
| Facility | | $229.09 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $245.47 / $707.95
| Professional | | $229.09 | $245.47 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $1,000.00
| Professional | | $281.84 | $407.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $7,413.10 / $13,182.57
| Facility | | $407.38 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,047.13 / $2,454.71
| Professional | | $616.60 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $1,000.00
| Professional | | $281.84 | $407.38 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $9,549.93 / $13,182.57
| Facility | | $6,309.57 | $9,549.93 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,905.46
| Professional | | $758.58 | $1,047.13 | $1,905.46 |