- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,819.70 / $2,818.38
| Facility | | $512.86 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $1,230.27
| Professional | | $512.86 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $1,122.02
| Professional | | $549.54 | $912.01 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $8,912.51
| Facility | | $724.44 | $1,445.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,513.56
| Professional | | $549.54 | $724.44 | $1,513.56 |