- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.52 / $1,907.09 / $2,000.00
| Facility | | $341.52 | $1,907.09 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.84 / $341.52 / $2,242.11
| Professional | | $151.84 | $341.52 | $2,242.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.03 / $834.78 / $5,212.54
| Professional | | $645.03 | $834.78 | $5,212.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.83 / $1,063.38 / $6,687.74
| Professional | | $228.83 | $1,063.38 | $6,687.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.19 / $553.46 / $3,560.71
| Facility | | $217.19 | $553.46 | $3,560.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.39 / $1,921.77 / $7,877.88
| Professional | | $274.39 | $1,921.77 | $7,877.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.82 / $2,113.94 / $4,227.89
| Professional | | $358.82 | $2,113.94 | $4,227.89 |