- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,894.00 / $1,894.00 / $14,482.00
| Facility | | $1,894.00 | $1,894.00 | $14,482.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.58 / $158.44 / $158.44
| Professional | | $134.58 | $158.44 | $158.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $1,455.00 / $2,090.40
| Facility | | $1,124.00 | $1,455.00 | $2,090.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,034.00 / $1,533.00 / $2,202.90
| Facility | | $1,034.00 | $1,533.00 | $2,202.90 |