- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $4,073.80 / $15,848.93
| Facility | | $371.54 | $4,073.80 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,000.00 / $1,862.09
| Professional | | $380.19 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,365.16 / $8,511.38
| Facility | | $3,388.44 | $4,365.16 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,230.27 / $4,365.16
| Facility | | $302.00 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $1,230.27 / $4,466.84
| Facility | | $309.03 | $1,230.27 | $4,466.84 |