- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $4,073.80 / $4,570.88
| Facility | | $407.38 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $467.74 / $1,000.00
| Professional | | $338.84 | $467.74 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,659.59 / $5,128.61
| Professional | | $331.13 | $1,659.59 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $489.78 / $1,071.52
| Professional | | $346.74 | $489.78 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $1,148.15
| Professional | | $524.81 | $616.60 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,803.84 / $26,302.68
| Facility | | $2,344.23 | $13,803.84 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $467.74 / $1,023.29
| Professional | | $316.23 | $467.74 | $1,023.29 |