- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,388.44 / $6,025.60
| Facility | | $2,454.71 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $2,454.71
| Professional | | $707.95 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $44.67 / $6,025.60
| Professional | | $32.36 | $44.67 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,311.31 / $3,548.13
| Professional | | $1,122.02 | $3,311.31 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,000.00 / $1,659.59
| Professional | | $407.38 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,290.87
| Professional | | $1,122.02 | $1,380.38 | $2,290.87 |