- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.79 / $1,615.00 / $10,924.00
| Facility | | $1,198.79 | $1,615.00 | $10,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.44 / $697.50 / $1,411.82
| Professional | | $249.44 | $697.50 | $1,411.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.10 / $606.10 / $606.10
| Facility | | $606.10 | $606.10 | $606.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.00 / $832.00 / $1,928.00
| Facility | | $361.00 | $832.00 | $1,928.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |