- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.32 / $1,342.00 / $3,804.00
| Facility | | $790.32 | $1,342.00 | $3,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.13 / $790.32 / $790.32
| Professional | | $592.13 | $790.32 | $790.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $1,150.14 / $1,150.14
| Professional | | $157.59 | $1,150.14 | $1,150.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.00 / $1,650.00 / $4,233.00
| Facility | | $980.00 | $1,650.00 | $4,233.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.83 / $693.26 / $1,201.29
| Professional | | $569.83 | $693.26 | $1,201.29 |