- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $616.60 / $912.01
| Professional | | $501.19 | $616.60 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,918.31 / $9,772.37
| Facility | | $4,073.80 | $6,918.31 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $891.25
| Professional | | $616.60 | $724.44 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $6,456.54 / $6,456.54
| Facility | | $39.81 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $1,000.00
| Professional | | $436.52 | $676.08 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $9,549.93
| Facility | | $1,023.29 | $3,548.13 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $630.96 / $1,000.00
| Professional | | $489.78 | $630.96 | $1,000.00 |