- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.89 / $1,313.00 / $3,109.00
| Facility | | $276.89 | $1,313.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.83 / $975.00 / $3,056.76
| Professional | | $157.83 | $975.00 | $3,056.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.31 / $2,637.06 / $5,189.82
| Professional | | $214.31 | $2,637.06 | $5,189.82 |
- 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
- $2,813.36 / $3,653.38 / $5,931.00
| Professional | | $2,813.36 | $3,653.38 | $5,931.00 |