- 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
- $174.56 / $192.03 / $245.20
| Professional | | $174.56 | $192.03 | $245.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,223.94 / $1,485.31 / $1,998.21
| Facility | | $1,223.94 | $1,485.31 | $1,998.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $3,816.00 / $7,227.00
| Facility | | $1,074.00 | $3,816.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.31 / $230.56 / $325.24
| Professional | | $187.31 | $230.56 | $325.24 |