- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $951.97 / $1,463.59
| Professional | | $100.00 | $951.97 | $1,463.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.14 / $524.14 / $1,066.22
| Facility | | $524.14 | $524.14 | $1,066.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.14 / $524.14 / $524.14
| Professional | | $524.14 | $524.14 | $524.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.10 / $772.66 / $1,467.59
| Professional | | $556.10 | $772.66 | $1,467.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.07 / $1,610.07 / $11,028.25
| Facility | | $1,610.07 | $1,610.07 | $11,028.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,443.79 / $3,443.79 / $3,443.79
| Professional | | $3,443.79 | $3,443.79 | $3,443.79 |