- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,235.94 / $9,772.37
| Facility | | $630.96 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $588.84 / $954.99
| Professional | | $173.78 | $588.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $9,772.37
| Professional | | $120.23 | $199.53 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $6,456.54 / $12,882.50
| Professional | | $562.34 | $6,456.54 | $12,882.50 |