- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,000.00 / $2,041.74
| Facility | | $371.54 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $354.81 / $416.87
| Professional | | $269.15 | $354.81 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $436.52
| Professional | | $323.59 | $323.59 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $524.81 / $588.84
| Professional | | $263.03 | $524.81 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $338.84 / $645.65
| Professional | | $269.15 | $338.84 | $645.65 |