- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $638.19 / $1,344.96 / $7,083.60
| Facility | | $638.19 | $1,344.96 | $7,083.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $690.18 / $1,075.92
| Professional | | $150.00 | $690.18 | $1,075.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,125.45 / $3,125.45 / $3,125.45
| Facility | | $3,125.45 | $3,125.45 | $3,125.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.65 / $1,359.75 / $2,917.89
| Facility | | $1,125.65 | $1,359.75 | $2,917.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.25 / $5.00 / $5.00
| Professional | | $4.25 | $5.00 | $5.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.62 / $572.62 / $572.62
| Professional | | $572.62 | $572.62 | $572.62 |