- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $3,235.94 / $9,772.37
| Facility | | $660.69 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,380.38
| Professional | | $660.69 | $660.69 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,691.53
| Facility | | $1,995.26 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $199.53 / $346.74
| Professional | | $100.00 | $199.53 | $346.74 |
- 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
- $1,174.90 / $2,290.87 / $4,786.30
| Facility | | $1,174.90 | $2,290.87 | $4,786.30 |