- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,513.56 / $2,454.71
| Facility | | $630.96 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $1,000.00
| Professional | | $446.68 | $616.60 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,951.21
| Facility | | $2,137.96 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $812.83
| Professional | | $602.56 | $602.56 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $741.31 / $1,023.29
| Professional | | $426.58 | $741.31 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $6,760.83
| Facility | | $977.24 | $2,041.74 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $602.56 / $1,023.29
| Professional | | $467.74 | $602.56 | $1,023.29 |