- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.83 / $1,759.00 / $5,106.60
| Facility | | $428.83 | $1,759.00 | $5,106.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.33 / $2,646.20 / $3,153.95
| Professional | | $219.33 | $2,646.20 | $3,153.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.64 / $2,720.09 / $5,354.20
| Professional | | $262.64 | $2,720.09 | $5,354.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,992.00
| Facility | | $1,565.00 | $2,828.00 | $6,992.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.24 / $3,900.22 / $6,502.08
| Professional | | $2,900.24 | $3,900.22 | $6,502.08 |