- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,511.89 / $7,762.47
| Facility | | $812.83 | $2,511.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $346.74 / $549.54
| Professional | | $218.78 | $346.74 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $3,548.13
| Facility | | $1,584.89 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,238.72 / $4,897.79
| Facility | | $891.25 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $630.96 / $1,000.00
| Professional | | $446.68 | $630.96 | $1,000.00 |