- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.04 / $2,000.00 / $3,796.41
| Facility | | $217.04 | $2,000.00 | $3,796.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $1,140.32 / $4,421.85
| Professional | | $208.00 | $1,140.32 | $4,421.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.07 / $4,644.51 / $6,965.60
| Professional | | $426.07 | $4,644.51 | $6,965.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.57 / $4,211.74 / $8,808.20
| Professional | | $337.57 | $4,211.74 | $8,808.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.04 / $3,796.41 / $5,246.59
| Facility | | $217.04 | $3,796.41 | $5,246.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,190.97 / $7,958.59 / $10,669.73
| Professional | | $4,190.97 | $7,958.59 | $10,669.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,809.98 / $6,964.51 / $8,842.87
| Professional | | $3,809.98 | $6,964.51 | $8,842.87 |