- 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
- $238.96 / $263.10 / $335.44
| Professional | | $238.96 | $263.10 | $335.44 |
- 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
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.33 / $315.56 / $445.08
| Professional | | $256.33 | $315.56 | $445.08 |