- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.04 / $1,775.00 / $4,123.34
| Facility | | $274.04 | $1,775.00 | $4,123.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.01 / $675.27 / $4,123.34
| Professional | | $171.01 | $675.27 | $4,123.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,644.41 / $5,636.21 / $7,582.51
| Facility | | $4,644.41 | $5,636.21 | $7,582.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.19 / $288.12 / $4,037.48
| Professional | | $165.19 | $288.12 | $4,037.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $3,816.00 / $7,227.00
| Facility | | $1,074.00 | $3,816.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.69 / $3,103.08 / $5,077.97
| Professional | | $2,348.69 | $3,103.08 | $5,077.97 |