- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $407.38 / $2,344.23
| Facility | | $309.03 | $407.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $407.38 / $1,000.00
| Professional | | $309.03 | $407.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $2,951.21
| Professional | | $1,905.46 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,905.46
| Professional | | $1,513.56 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $416.87 / $1,949.84
| Facility | | $263.03 | $416.87 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $616.60 / $1,548.82
| Professional | | $208.93 | $616.60 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $602.56 / $1,479.11
| Professional | | $186.21 | $602.56 | $1,479.11 |