- 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
- $191.84 / $207.35 / $269.47
| Professional | | $191.84 | $207.35 | $269.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,486.62 / $5,444.73 / $7,324.90
| Facility | | $4,486.62 | $5,444.73 | $7,324.90 |
- 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
- $211.40 / $267.77 / $352.33
| Professional | | $211.40 | $267.77 | $352.33 |