- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $1,450.00 / $3,412.00
| Facility | | $640.00 | $1,450.00 | $3,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.71 / $270.04 / $305.72
| Professional | | $245.71 | $270.04 | $305.72 |
- 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
- $375.00 / $1,213.00 / $2,488.00
| Facility | | $375.00 | $1,213.00 | $2,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.63 / $355.86 / $551.87
| Professional | | $263.63 | $355.86 | $551.87 |