- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $8,128.31
| Facility | | $2,398.83 | $2,398.83 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $229.09
| Professional | | $1.00 | $1.00 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $7,413.10
| Facility | | $3,388.44 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $7,413.10
| Facility | | $3,388.44 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $4,168.69
| Facility | | $2,511.89 | $3,388.44 | $4,168.69 |