- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,048.00 / $3,779.00 / $12,600.00
| Facility | | $1,048.00 | $3,779.00 | $12,600.00 |
- 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
- $367.50 / $1,091.00 / $7,718.62
| Facility | | $367.50 | $1,091.00 | $7,718.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.27 / $2,295.27 / $2,295.27
| Professional | | $2,295.27 | $2,295.27 | $2,295.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.00 / $3,858.00 / $7,077.94
| Facility | | $1,157.00 | $3,858.00 | $7,077.94 |