- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $2,095.00 / $7,838.38
| Facility | | $655.61 | $2,095.00 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $1,383.34
| Professional | | $655.61 | $655.61 | $1,383.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $85.00
| Professional | | $45.00 | $60.00 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $557.27 / $557.27 / $557.27
| Facility | | $557.27 | $557.27 | $557.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $559.00 / $3,503.00 / $5,060.00
| Facility | | $559.00 | $3,503.00 | $5,060.00 |