- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $6,165.95
| Facility | | $831.76 | $2,884.03 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $1,000.00
| Professional | | $436.52 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,467.37 / $6,309.57
| Facility | | $1,412.54 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $1,318.26
| Professional | | $245.47 | $245.47 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $3,467.37
| Facility | | $691.83 | $851.14 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $691.83 / $1,905.46
| Professional | | $302.00 | $691.83 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,862.09 / $3,548.13
| Professional | | $851.14 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,318.26 / $1,318.26
| Professional | | $588.84 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $1,318.26
| Facility | | $436.52 | $588.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $331.13 / $436.52
| Professional | | $245.47 | $331.13 | $436.52 |