- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.41 / $1,342.00 / $3,804.00
| Facility | | $508.41 | $1,342.00 | $3,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.10 / $508.41 / $585.63
| Professional | | $412.10 | $508.41 | $585.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,027.36 / $3,027.36 / $3,632.83
| Facility | | $3,027.36 | $3,027.36 | $3,632.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.96 / $708.03 / $708.03
| Professional | | $534.96 | $708.03 | $708.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.48 / $777.80 / $927.31
| Professional | | $437.48 | $777.80 | $927.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,931.00 / $9,199.04
| Facility | | $1,240.00 | $2,931.00 | $9,199.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.83 / $555.58 / $993.15
| Professional | | $439.83 | $555.58 | $993.15 |