- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,288.25 / $1,995.26
| Facility | | $549.54 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $478.63 / $1,202.26
| Professional | | $416.87 | $478.63 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $4,365.16
| Facility | | $1,698.24 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $1,071.52
| Professional | | $436.52 | $691.83 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,235.94 / $7,244.36
| Facility | | $851.14 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $1,000.00
| Professional | | $426.58 | $575.44 | $1,000.00 |