- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,818.38
| Facility | | $776.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,000.00 / $1,000.00
| Facility | | $524.81 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $39.81
| Professional | | $21.38 | $25.12 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $575.44 / $1,621.81
| Facility | | $309.03 | $575.44 | $1,621.81 |