- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $450.00 / $942.00
| Professional | | $250.00 | $450.00 | $942.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.28 / $397.75 / $530.82
| Facility | | $181.28 | $397.75 | $530.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.00 / $1,183.00 / $4,915.00
| Facility | | $320.00 | $1,183.00 | $4,915.00 |