- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.63 / $2,175.28 / $4,100.00
| Facility | | $511.63 | $2,175.28 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.42 / $898.88 / $906.32
| Professional | | $211.42 | $898.88 | $906.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.79 / $220.53 / $2,642.00
| Professional | | $156.79 | $220.53 | $2,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.18 / $692.34 / $2,516.87
| Professional | | $206.18 | $692.34 | $2,516.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.00 / $1,842.28 / $1,842.28
| Professional | | $796.00 | $1,842.28 | $1,842.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $2,343.00 / $26,408.00
| Facility | | $1,832.00 | $2,343.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.96 / $1,537.27 / $2,134.57
| Professional | | $736.96 | $1,537.27 | $2,134.57 |