- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.47 / $2,563.00 / $6,446.00
| Facility | | $896.47 | $2,563.00 | $6,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.20 / $600.00 / $2,846.31
| Professional | | $123.20 | $600.00 | $2,846.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.83 / $653.62 / $2,126.00
| Facility | | $309.83 | $653.62 | $2,126.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,623.00 / $2,126.00
| Facility | | $1,204.00 | $1,623.00 | $2,126.00 |