- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $346.74 / $1,148.15
| Professional | | $169.82 | $346.74 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $446.68 / $1,047.13
| Professional | | $173.78 | $446.68 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,621.81 / $1,621.81
| Facility | | $588.84 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $407.38 / $1,318.26
| Professional | | $199.53 | $407.38 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $5,495.41
| Facility | | $794.33 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $371.54 / $1,000.00
| Professional | | $173.78 | $371.54 | $1,000.00 |