- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.66 / $1,268.00 / $2,250.00
| Facility | | $326.66 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.27 / $326.66 / $512.66
| Professional | | $237.27 | $326.66 | $512.66 |
- 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
- $513.34 / $684.75 / $972.44
| Professional | | $513.34 | $684.75 | $972.44 |