- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.20 / $1,821.00 / $9,477.00
| Facility | | $264.20 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.20 / $264.20 / $455.57
| Professional | | $264.20 | $264.20 | $455.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.03 / $547.73 / $773.06
| Professional | | $376.03 | $547.73 | $773.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.92 / $377.97 / $937.90
| Professional | | $271.92 | $377.97 | $937.90 |