- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,012.17 / $5,621.00 / $16,467.00
| Facility | | $3,012.17 | $5,621.00 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,292.22 / $1,292.22
| Professional | | $1,100.00 | $1,292.22 | $1,292.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.64 / $422.59 / $687.05
| Facility | | $208.64 | $422.59 | $687.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $890.00 / $890.00 / $890.00
| Facility | | $890.00 | $890.00 | $890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.00 / $1,134.00 / $2,922.00
| Facility | | $358.00 | $1,134.00 | $2,922.00 |