- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.00 / $1,525.00 / $2,250.00
| Facility | | $781.00 | $1,525.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.61 / $333.87 / $377.58
| Professional | | $285.61 | $333.87 | $377.58 |
- 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
- $1,500.00 / $6,466.00 / $12,422.00
| Facility | | $1,500.00 | $6,466.00 | $12,422.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.32 / $342.01 / $516.75
| Professional | | $255.32 | $342.01 | $516.75 |