- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.50 / $1,632.00 / $4,478.00
| Facility | | $367.50 | $1,632.00 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $367.50
| Professional | | $367.50 | $367.50 | $367.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,308.46 / $3,308.46 / $3,970.15
| Facility | | $3,308.46 | $3,308.46 | $3,970.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,414.94 / $2,414.94 / $2,414.94
| Facility | | $2,414.94 | $2,414.94 | $2,414.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.64 / $262.64 / $300.00
| Professional | | $262.64 | $262.64 | $300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,311.00 / $5,626.00
| Facility | | $1,240.00 | $2,311.00 | $5,626.00 |