- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.25 / $3,391.00 / $6,915.00
| Facility | | $954.25 | $3,391.00 | $6,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.58 / $1,017.80 / $3,291.40
| Professional | | $720.58 | $1,017.80 | $3,291.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.03 / $4,429.60 / $8,135.37
| Facility | | $699.03 | $4,429.60 | $8,135.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $2,500.00
| Facility | | $500.00 | $500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.00 / $1,550.00 / $2,506.00
| Facility | | $384.00 | $1,550.00 | $2,506.00 |