- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.08 / $67.08 / $8,221.08
| Facility | | $67.08 | $67.08 | $8,221.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,553.00 / $3,553.00 / $3,553.00
| Professional | | $3,553.00 | $3,553.00 | $3,553.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.84 / $465.40 / $1,899.75
| Facility | | $0.84 | $465.40 | $1,899.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.79 / $1,111.59 / $2,578.80
| Professional | | $555.79 | $1,111.59 | $2,578.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.40 / $465.40 / $465.40
| Facility | | $465.40 | $465.40 | $465.40 |