- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,905.46 / $4,570.88
| Facility | | $501.19 | $1,905.46 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $446.68 / $977.24
| Professional | | $309.03 | $446.68 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $2,089.30 / $5,495.41
| Professional | | $323.59 | $2,089.30 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $501.19 / $1,174.90
| Professional | | $338.84 | $501.19 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $776.25 / $1,122.02
| Professional | | $562.34 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,760.83 / $26,302.68
| Facility | | $1,023.29 | $6,760.83 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $489.78 / $1,000.00
| Professional | | $316.23 | $489.78 | $1,000.00 |