- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.19 / $1,842.54 / $1,842.54
| Professional | | $915.19 | $1,842.54 | $1,842.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.50 / $707.16 / $2,126.00
| Facility | | $336.50 | $707.16 | $2,126.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.92 / $697.96 / $1,966.00
| Facility | | $304.92 | $697.96 | $1,966.00 |