- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.16 / $1,754.26 / $2,825.00
| Facility | | $734.16 | $1,754.26 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.16 / $1,413.67 / $3,663.08
| Professional | | $734.16 | $1,413.67 | $3,663.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.00 / $1,831.00 / $1,831.00
| Professional | | $1,831.00 | $1,831.00 | $1,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.05 / $1,336.07 / $2,027.18
| Professional | | $797.05 | $1,336.07 | $2,027.18 |
- 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 / $8,817.00
| Facility | | $690.00 | $1,236.00 | $8,817.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.73 / $1,047.51 / $2,175.38
| Professional | | $784.73 | $1,047.51 | $2,175.38 |