- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.00 / $1,414.00 / $3,412.00
| Facility | | $781.00 | $1,414.00 | $3,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.21 / $422.68 / $477.74
| Professional | | $384.21 | $422.68 | $477.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.30 / $2,745.40 / $3,693.45
| Facility | | $2,262.30 | $2,745.40 | $3,693.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $3,129.00 / $5,251.00
| Facility | | $950.00 | $3,129.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.72 / $541.04 / $823.64
| Professional | | $425.72 | $541.04 | $823.64 |