- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $6,025.60 / $7,413.10
| Facility | | $707.95 | $6,025.60 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $588.84 / $1,071.52
| Professional | | $302.00 | $588.84 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $371.54 / $602.56
| Professional | | $245.47 | $371.54 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,918.31
| Facility | | $6,606.93 | $6,606.93 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $354.81 / $741.31
| Professional | | $229.09 | $354.81 | $741.31 |