- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $2,344.23 / $5,623.41
| Facility | | $407.38 | $2,344.23 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $851.14 / $1,819.70
| Professional | | $371.54 | $851.14 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $11,220.18
| Facility | | $4,265.80 | $8,709.64 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,000.00 / $5,370.32
| Professional | | $398.11 | $1,000.00 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $954.99 / $4,570.88
| Facility | | $416.87 | $954.99 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $691.83 / $3,548.13
| Professional | | $363.08 | $691.83 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,888.44 / $10,715.19
| Facility | | $2,137.96 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $776.25 / $3,548.13
| Professional | | $354.81 | $776.25 | $3,548.13 |