- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,375.00 / $7,660.09 / $9,707.54
| Facility | | $4,375.00 | $7,660.09 | $9,707.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.86 / $527.86 / $7,500.00
| Professional | | $527.86 | $527.86 | $7,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.16 / $294.10 / $462.31
| Facility | | $147.16 | $294.10 | $462.31 |
- 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
- $225.00 / $1,221.00 / $3,585.00
| Facility | | $225.00 | $1,221.00 | $3,585.00 |