- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.64 / $1,614.00 / $7,727.00
| Facility | | $304.64 | $1,614.00 | $7,727.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.62 / $304.64 / $482.11
| Professional | | $185.62 | $304.64 | $482.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.72 / $304.97 / $627.33
| Professional | | $289.72 | $304.97 | $627.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.00 / $1,319.00 / $16,382.00
| Facility | | $645.00 | $1,319.00 | $16,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.65 / $601.69 / $1,115.25
| Professional | | $417.65 | $601.69 | $1,115.25 |