- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.83 / $1,268.00 / $2,250.00
| Facility | | $136.83 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.19 / $136.83 / $154.72
| Professional | | $124.19 | $136.83 | $154.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,569.65 / $6,759.03 / $9,093.06
| Facility | | $5,569.65 | $6,759.03 | $9,093.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $3,816.00 / $7,227.00
| Facility | | $1,074.00 | $3,816.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.39 / $169.40 / $246.79
| Professional | | $116.39 | $169.40 | $246.79 |