- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.75 / $1,662.91 / $4,478.00
| Facility | | $533.75 | $1,662.91 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.89 / $1,221.97 / $2,112.54
| Professional | | $276.89 | $1,221.97 | $2,112.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,029.72 / $3,029.72 / $3,635.66
| Facility | | $3,029.72 | $3,029.72 | $3,635.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.52 / $431.64 / $1,988.38
| Professional | | $293.52 | $431.64 | $1,988.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.86 / $581.41 / $2,698.29
| Professional | | $471.86 | $581.41 | $2,698.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,314.00 / $5,652.00
| Facility | | $1,240.00 | $2,314.00 | $5,652.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.63 / $2,018.16 / $3,056.85
| Professional | | $1,433.63 | $2,018.16 | $3,056.85 |