- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.93 / $1,268.00 / $2,250.00
| Facility | | $215.93 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.80 / $215.93 / $301.11
| Professional | | $192.80 | $215.93 | $301.11 |
- 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
- $22.57 / $244.59 / $546.25
| Professional | | $22.57 | $244.59 | $546.25 |