- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,776.00 / $5,866.00 / $16,467.00
| Facility | | $3,776.00 | $5,866.00 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,776.00 / $3,776.00 / $9,062.00
| Professional | | $3,776.00 | $3,776.00 | $9,062.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.88 / $2,617.13 / $4,109.81
| Facility | | $1,331.88 | $2,617.13 | $4,109.81 |
- 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 |