- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $580.91 / $2,678.00 / $7,602.00
| Facility | | $580.91 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.21 / $183.25 / $217.47
| Professional | | $115.21 | $183.25 | $217.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.00 / $341.00 / $801.35
| Professional | | $341.00 | $341.00 | $801.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.16 / $5,062.89 / $5,062.89
| Facility | | $379.16 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.79 / $1,334.79 / $1,876.80
| Professional | | $1,334.79 | $1,334.79 | $1,876.80 |