- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $1,759.53 / $6,843.54
| Facility | | $0.98 | $1,759.53 | $6,843.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.36 / $4,189.43 / $4,189.43
| Professional | | $0.36 | $4,189.43 | $4,189.43 |
- 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 |