- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.02 / $2,970.02 / $4,387.00
| Facility | | $503.02 | $2,970.02 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,685.28 / $3,231.73
| Professional | | $346.74 | $1,685.28 | $3,231.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.56 / $794.65 / $3,259.60
| Professional | | $406.56 | $794.65 | $3,259.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.71 / $1,506.48 / $1,970.98
| Professional | | $1,215.71 | $1,506.48 | $1,970.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.78 / $2,326.73 / $3,850.00
| Professional | | $460.78 | $2,326.73 | $3,850.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.96 / $2,331.64 / $4,002.10
| Professional | | $1,833.96 | $2,331.64 | $4,002.10 |