- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,754.23 / $4,073.80
| Facility | | $660.69 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $501.19 / $741.31
| Professional | | $346.74 | $501.19 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $407.38 / $3,235.94
| Professional | | $338.84 | $407.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $524.81 / $1,513.56
| Professional | | $346.74 | $524.81 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $1,023.29
| Professional | | $524.81 | $616.60 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $6,606.93 / $26,302.68
| Facility | | $812.83 | $6,606.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $489.78 / $1,000.00
| Professional | | $309.03 | $489.78 | $1,000.00 |