- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,862.09 / $5,888.44
| Facility | | $512.86 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $5,128.61
| Facility | | $912.01 | $1,148.15 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $588.84 / $1,445.44
| Professional | | $323.59 | $588.84 | $1,445.44 |
- 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
- $588.84 / $1,479.11 / $3,801.89
| Facility | | $588.84 | $1,479.11 | $3,801.89 |