- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.05 / $1,268.00 / $2,250.00
| Facility | | $928.05 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.72 / $928.05 / $1,392.69
| Professional | | $536.72 | $928.05 | $1,392.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,510.84 / $6,687.67 / $8,997.06
| Facility | | $5,510.84 | $6,687.67 | $8,997.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.00 / $2,891.00 / $4,402.00
| Facility | | $834.00 | $2,891.00 | $4,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.21 / $1,992.15 / $2,985.44
| Professional | | $1,415.21 | $1,992.15 | $2,985.44 |