- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.76 / $1,514.00 / $2,076.00
| Facility | | $603.76 | $1,514.00 | $2,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Professional | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.58 / $1,239.98 / $1,319.72
| Facility | | $1,031.58 | $1,239.98 | $1,319.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.00 / $575.00 / $651.00
| Professional | | $575.00 | $575.00 | $651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,560.41 / $3,535.68
| Facility | | $100.00 | $1,560.41 | $3,535.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.58 / $683.32 / $1,110.33
| Facility | | $481.58 | $683.32 | $1,110.33 |