- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,388.44 / $6,025.60
| Facility | | $1,023.29 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,737.80
| Professional | | $691.83 | $831.76 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $1,659.59
| Professional | | $575.44 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $1,659.59
| Professional | | $32.36 | $33.11 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $1,659.59
| Professional | | $1,023.29 | $1,288.25 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,621.81 / $2,238.72
| Professional | | $724.44 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $1,737.80
| Professional | | $912.01 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,380.38
| Professional | | $676.08 | $870.96 | $1,380.38 |