- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,168.00 / $4,698.26 / $4,698.26
| Facility | | $2,168.00 | $4,698.26 | $4,698.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.40 / $2,024.45 / $2,024.45
| Professional | | $626.40 | $2,024.45 | $2,024.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.48 / $543.89 / $953.66
| Facility | | $358.48 | $543.89 | $953.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.14 / $421.14 / $877.07
| Professional | | $421.14 | $421.14 | $877.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.00 / $1,438.00 / $8,547.74
| Facility | | $331.00 | $1,438.00 | $8,547.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.00 / $1,971.00 / $6,582.60
| Professional | | $1,404.00 | $1,971.00 | $6,582.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.00 / $1,727.00 / $2,883.00
| Facility | | $382.00 | $1,727.00 | $2,883.00 |