- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,754.23 / $4,897.79
| Facility | | $776.25 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,090.30
| Professional | | $2,754.23 | $2,754.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $5,370.32
| Facility | | $2,754.23 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $2,754.23 / $3,981.07
| Professional | | $114.82 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $2,754.23 / $2,754.23
| Facility | | $223.87 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $2,754.23 / $2,754.23
| Professional | | $117.49 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $151.36 / $302.00
| Facility | | $93.33 | $151.36 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $125.89 / $3,467.37
| Professional | | $107.15 | $125.89 | $3,467.37 |