- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.00 / $1,615.00 / $10,924.00
| Facility | | $1,245.00 | $1,615.00 | $10,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.12 / $3,696.77 / $22,840.30
| Professional | | $349.12 | $3,696.77 | $22,840.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $105.13 / $105.13
| Professional | | $105.13 | $105.13 | $105.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $905.00 / $2,417.00 / $4,102.00
| Facility | | $905.00 | $2,417.00 | $4,102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |