- 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
- $291.13 / $291.13 / $329.55
| Professional | | $291.13 | $291.13 | $329.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,049.26 / $13,408.80 / $18,039.12
| Facility | | $11,049.26 | $13,408.80 | $18,039.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.00 / $6,323.00 / $12,422.00
| Facility | | $1,500.00 | $6,323.00 | $12,422.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.52 / $445.94 / $679.35
| Professional | | $324.52 | $445.94 | $679.35 |