- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $7,244.36
| Facility | | $870.96 | $1,230.27 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $501.19 / $1,174.90
| Professional | | $338.84 | $501.19 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $776.25
| Professional | | $354.81 | $501.19 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- 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
- $331.13 / $457.09 / $758.58
| Professional | | $331.13 | $457.09 | $758.58 |