- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.57 / $1,728.00 / $2,250.00
| Facility | | $290.57 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.68 / $290.57 / $525.77
| Professional | | $262.68 | $290.57 | $525.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,496.20 / $10,310.54 / $13,870.99
| Facility | | $8,496.20 | $10,310.54 | $13,870.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $4,083.00
| Facility | | $650.00 | $1,754.00 | $4,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.92 / $538.46 / $879.88
| Professional | | $376.92 | $538.46 | $879.88 |