- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.55 / $1,593.13 / $4,352.68
| Facility | | $883.55 | $1,593.13 | $4,352.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $317.14 / $2,481.05
| Professional | | $120.00 | $317.14 | $2,481.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.00 / $1,712.00 / $1,712.00
| Professional | | $1,712.00 | $1,712.00 | $1,712.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.00 / $485.00 / $513.90
| Facility | | $485.00 | $485.00 | $513.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.00 / $445.00 / $445.00
| Facility | | $445.00 | $445.00 | $445.00 |