- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.45 / $1,728.00 / $2,250.00
| Facility | | $362.45 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.81 / $362.45 / $463.02
| Professional | | $277.81 | $362.45 | $463.02 |
- 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
- $344.33 / $486.16 / $815.78
| Professional | | $344.33 | $486.16 | $815.78 |