- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.05 / $1,268.00 / $2,250.00
| Facility | | $176.05 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.73 / $176.05 / $232.44
| Professional | | $164.73 | $176.05 | $232.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,250.52 / $10,012.39 / $13,469.87
| Facility | | $8,250.52 | $10,012.39 | $13,469.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.48 / $11,985.00 / $13,014.00
| Facility | | $1,038.48 | $11,985.00 | $13,014.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.26 / $204.62 / $286.47
| Professional | | $142.26 | $204.62 | $286.47 |