- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,513.56 / $2,454.71
| Facility | | $302.00 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,380.38 / $2,691.53
| Professional | | $208.93 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,570.40
| Facility | | $1,905.46 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $3,090.30
| Professional | | $223.87 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $501.19 / $3,630.78
| Professional | | $288.40 | $501.19 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,445.44 / $5,248.07
| Facility | | $602.56 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $1,412.54 / $3,090.30
| Professional | | $213.80 | $1,412.54 | $3,090.30 |