- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,279.83 / $2,279.83 / $13,092.85
| Facility | | $2,279.83 | $2,279.83 | $13,092.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $1,216.21 / $2,589.30
| Professional | | $525.00 | $1,216.21 | $2,589.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,701.00 / $3,701.00 / $3,701.00
| Professional | | $3,701.00 | $3,701.00 | $3,701.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.00 / $37.00 / $41.00
| Facility | | $36.00 | $37.00 | $41.00 |