- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,698.24 / $4,365.16
| Facility | | $660.69 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,000.00 / $5,370.32
| Professional | | $79.43 | $1,000.00 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Professional | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,122.02 / $2,089.30
| Facility | | $602.56 | $1,122.02 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $158.49 / $5,495.41
| Professional | | $79.43 | $158.49 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $676.08 / $4,897.79
| Facility | | $213.80 | $676.08 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,584.89 / $2,754.23
| Professional | | $89.13 | $1,584.89 | $2,754.23 |