- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $7,585.78
| Facility | | $1,819.70 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,479.11
| Professional | | $1,202.26 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $407.38
| Facility | | $104.71 | $147.91 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |