- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.10 / $1,290.31 / $3,109.00
| Facility | | $878.10 | $1,290.31 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.50 / $878.10 / $1,020.45
| Professional | | $652.50 | $878.10 | $1,020.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.28 / $977.85 / $1,035.36
| Professional | | $782.28 | $977.85 | $1,035.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.20 / $1,080.10 / $1,368.05
| Professional | | $793.20 | $1,080.10 | $1,368.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,334.00 / $8,676.00
| Facility | | $2,104.00 | $4,334.00 | $8,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.07 / $920.72 / $1,381.39
| Professional | | $659.07 | $920.72 | $1,381.39 |