- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $885.60 / $2,290.00 / $4,767.89
| Facility | | $885.60 | $2,290.00 | $4,767.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.06 / $315.06 / $1,485.90
| Professional | | $315.06 | $315.06 | $1,485.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $1,769.72
| Facility | | $821.00 | $821.00 | $1,769.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Professional | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |