- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $938.07 / $1,096.20 / $1,768.14
| Facility | | $938.07 | $1,096.20 | $1,768.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.09 / $594.02 / $675.03
| Professional | | $402.09 | $594.02 | $675.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,509.35 / $6,509.35 / $6,509.35
| Facility | | $6,509.35 | $6,509.35 | $6,509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.31 / $1,500.31 / $1,500.31
| Professional | | $1,500.31 | $1,500.31 | $1,500.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,509.35 / $6,509.35 / $6,509.35
| Facility | | $6,509.35 | $6,509.35 | $6,509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.36 / $1,500.31 / $1,500.31
| Professional | | $879.36 | $1,500.31 | $1,500.31 |