- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.77 / $2,562.00 / $4,050.00
| Facility | | $157.77 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.05 / $151.07 / $172.22
| Professional | | $148.05 | $151.07 | $172.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,135.14 / $7,795.18 / $11,905.69
| Facility | | $4,135.14 | $7,795.18 | $11,905.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.30 / $219.05 / $313.70
| Professional | | $143.30 | $219.05 | $313.70 |