- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.30 / $2,678.00 / $7,602.00
| Facility | | $773.30 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.92 / $155.06 / $185.84
| Professional | | $96.92 | $155.06 | $185.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.00 / $295.00 / $693.25
| Professional | | $295.00 | $295.00 | $693.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.14 / $5,062.89 / $5,062.89
| Facility | | $316.14 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.36 / $1,116.36 / $1,564.80
| Professional | | $1,116.36 | $1,116.36 | $1,564.80 |