- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $2,344.23 / $13,489.63
| Facility | | $389.05 | $2,344.23 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $891.25 / $5,623.41
| Professional | | $363.08 | $891.25 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $741.31 / $2,398.83
| Professional | | $363.08 | $741.31 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,000.00 / $2,238.72
| Professional | | $371.54 | $1,000.00 | $2,238.72 |