- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.62 / $1,632.00 / $4,478.00
| Facility | | $318.62 | $1,632.00 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.34 / $318.62 / $588.86
| Professional | | $244.34 | $318.62 | $588.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.50 / $1,489.64 / $1,655.15
| Professional | | $1,125.50 | $1,489.64 | $1,655.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $3,356.00 / $6,957.00
| Facility | | $1,565.00 | $3,356.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.71 / $357.28 / $581.74
| Professional | | $252.71 | $357.28 | $581.74 |