- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,445.44 / $8,317.64
| Facility | | $562.34 | $1,445.44 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,230.27 / $1,949.84
| Professional | | $562.34 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,148.15
| Professional | | $562.34 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $7,079.46 / $10,715.19
| Facility | | $2,630.27 | $7,079.46 | $10,715.19 |
- 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
- $549.54 / $776.25 / $1,513.56
| Professional | | $549.54 | $776.25 | $1,513.56 |