- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,754.23 / $4,073.80
| Facility | | $446.68 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $1,000.00
| Professional | | $346.74 | $407.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,071.52 / $2,454.71
| Professional | | $398.11 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $1,122.02
| Professional | | $398.11 | $524.81 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $1,000.00
| Professional | | $501.19 | $831.76 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $549.54 / $7,943.28
| Facility | | $213.80 | $549.54 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $524.81 / $1,096.48
| Professional | | $302.00 | $524.81 | $1,096.48 |