- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.47 / $3,788.96 / $8,500.00
| Facility | | $217.47 | $3,788.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.25 / $199.40 / $264.75
| Professional | | $183.25 | $199.40 | $264.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.95 / $1,582.04 / $4,826.16
| Facility | | $746.95 | $1,582.04 | $4,826.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.20 / $282.25 / $374.37
| Professional | | $228.20 | $282.25 | $374.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.39 / $311.70 / $311.70
| Professional | | $264.39 | $311.70 | $311.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.50 / $277.50 / $366.50
| Professional | | $262.50 | $277.50 | $366.50 |