- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.27 / $3,038.00 / $4,387.00
| Facility | | $117.27 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.27 / $117.27 / $117.27
| Professional | | $117.27 | $117.27 | $117.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,256.41 / $2,909.16 / $4,239.47
| Facility | | $2,256.41 | $2,909.16 | $4,239.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $2,312.00 / $4,640.00
| Facility | | $1,689.00 | $2,312.00 | $4,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.65 / $150.47 / $177.99
| Professional | | $119.65 | $150.47 | $177.99 |