- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.65 / $1,070.00 / $2,812.00
| Facility | | $621.65 | $1,070.00 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.37 / $617.12 / $755.94
| Professional | | $477.37 | $617.12 | $755.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.12 / $726.40 / $769.13
| Professional | | $581.12 | $726.40 | $769.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.45 / $805.40 / $1,013.74
| Professional | | $559.45 | $805.40 | $1,013.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.88 / $620.09 / $1,023.64
| Professional | | $475.88 | $620.09 | $1,023.64 |