- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,000.00 / $2,041.74
| Facility | | $338.84 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $316.23 / $501.19
| Professional | | $239.88 | $316.23 | $501.19 |
- 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
- $281.84 / $281.84 / $371.54
| Professional | | $281.84 | $281.84 | $371.54 |
- 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
- $239.88 / $457.09 / $512.86
| Professional | | $239.88 | $457.09 | $512.86 |
- 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
- $239.88 / $295.12 / $549.54
| Professional | | $239.88 | $295.12 | $549.54 |