- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.54 / $1,571.18 / $2,825.00
| Facility | | $657.54 | $1,571.18 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.54 / $1,266.22 / $3,280.79
| Professional | | $657.54 | $1,266.22 | $3,280.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.00 / $2,284.00 / $2,284.00
| Professional | | $2,284.00 | $2,284.00 | $2,284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.59 / $1,193.14 / $1,824.80
| Professional | | $713.59 | $1,193.14 | $1,824.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.00 / $1,236.00 / $5,253.00
| Facility | | $690.00 | $1,236.00 | $5,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.85 / $1,029.18 / $1,942.66
| Professional | | $701.85 | $1,029.18 | $1,942.66 |