- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.57 / $7,724.00 / $20,939.36
| Facility | | $0.57 | $7,724.00 | $20,939.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.63 / $219.63 / $1,245.00
| Professional | | $219.63 | $219.63 | $1,245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.78 / $710.78 / $710.78
| Professional | | $710.78 | $710.78 | $710.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,293.00 / $12,216.00 / $19,066.00
| Facility | | $5,293.00 | $12,216.00 | $19,066.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,160.00 / $10,160.00 / $10,160.00
| Facility | | $10,160.00 | $10,160.00 | $10,160.00 |