- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $767.92 / $1,268.00 / $2,250.00
| Facility | | $767.92 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.33 / $767.92 / $983.23
| Professional | | $698.33 | $767.92 | $983.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,486.62 / $5,444.73 / $7,324.90
| Facility | | $4,486.62 | $5,444.73 | $7,324.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.00 / $4,121.00 / $7,331.00
| Facility | | $1,196.00 | $4,121.00 | $7,331.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.82 / $1,073.21 / $1,684.94
| Professional | | $789.82 | $1,073.21 | $1,684.94 |