- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,288.25 / $1,995.26
| Facility | | $549.54 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,148.15
| Professional | | $467.74 | $549.54 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $3,019.95
| Facility | | $2,187.76 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $933.25
| Professional | | $467.74 | $630.96 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,691.53 / $6,918.31
| Facility | | $812.83 | $2,691.53 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $1,000.00
| Professional | | $416.87 | $562.34 | $1,000.00 |