- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.25 / $1,253.01 / $2,168.00
| Facility | | $486.25 | $1,253.01 | $2,168.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.65 / $2,001.65 / $2,707.20
| Professional | | $2,001.65 | $2,001.65 | $2,707.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.48 / $543.89 / $953.66
| Facility | | $358.48 | $543.89 | $953.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.04 / $617.04 / $2,699.26
| Professional | | $617.04 | $617.04 | $2,699.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.00 / $1,364.90 / $4,527.04
| Facility | | $331.00 | $1,364.90 | $4,527.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.70 / $1,425.00 / $2,973.60
| Professional | | $380.70 | $1,425.00 | $2,973.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.00 / $1,438.00 / $2,883.00
| Facility | | $382.00 | $1,438.00 | $2,883.00 |