- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,684.00 / $18,600.00
| Facility | | $1,000.00 | $3,684.00 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.34 / $251.34 / $254.29
| Professional | | $251.34 | $251.34 | $254.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.00 / $503.00 / $503.00
| Professional | | $503.00 | $503.00 | $503.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.34 / $267.00 / $745.20
| Facility | | $251.34 | $267.00 | $745.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.89 / $801.17 / $2,713.22
| Professional | | $248.89 | $801.17 | $2,713.22 |