- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,000.00 / $3,235.94
| Professional | | $79.43 | $1,000.00 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $977.24
| Facility | | $616.60 | $724.44 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $645.65 / $1,659.59
| Facility | | $251.19 | $645.65 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $1,380.38 / $2,238.72
| Professional | | $77.62 | $1,380.38 | $2,238.72 |