- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.77 / $2,477.00 / $9,477.00
| Facility | | $295.77 | $2,477.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.81 / $1,846.00 / $3,402.15
| Professional | | $150.81 | $1,846.00 | $3,402.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.26 / $317.81 / $4,881.81
| Professional | | $206.26 | $317.81 | $4,881.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,920.00 / $6,992.00
| Facility | | $1,565.00 | $2,920.00 | $6,992.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.23 / $3,421.24 / $5,554.09
| Professional | | $2,773.23 | $3,421.24 | $5,554.09 |