- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.45 / $878.00 / $6,906.00
| Facility | | $311.45 | $878.00 | $6,906.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.47 / $311.45 / $335.44
| Professional | | $210.47 | $311.45 | $335.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.45 / $4,933.00 / $6,907.00
| Facility | | $311.45 | $4,933.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.45 / $311.45 / $345.40
| Professional | | $311.45 | $311.45 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.00 / $4,566.00 / $6,740.00
| Facility | | $850.00 | $4,566.00 | $6,740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.66 / $422.10 / $571.17
| Professional | | $360.66 | $422.10 | $571.17 |