- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.86 / $5,348.23 / $8,625.00
| Facility | | $2,103.86 | $5,348.23 | $8,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.19 / $3,603.60 / $11,625.15
| Professional | | $173.19 | $3,603.60 | $11,625.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.00 / $391.00 / $592.00
| Professional | | $326.00 | $391.00 | $592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.06 / $346.38 / $708.33
| Professional | | $243.06 | $346.38 | $708.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.80 / $391.84 / $2,269.79
| Professional | | $282.80 | $391.84 | $2,269.79 |