- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.00 / $5,503.00 / $10,651.00
| Facility | | $2,551.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.20 / $805.20 / $805.20
| Professional | | $805.20 | $805.20 | $805.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.08 / $154.34 / $249.38
| Professional | | $114.08 | $154.34 | $249.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.20 / $805.20 / $1,288.32
| Facility | | $805.20 | $805.20 | $1,288.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,640.00 / $8,535.00 / $12,740.00
| Facility | | $2,640.00 | $8,535.00 | $12,740.00 |