- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.00 / $2,145.78 / $7,838.38
| Facility | | $1,047.00 | $2,145.78 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.19 / $161.19 / $322.39
| Professional | | $161.19 | $161.19 | $322.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,967.48 / $9,777.14 / $15,945.24
| Facility | | $3,967.48 | $9,777.14 | $15,945.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $70.00 / $1,500.00
| Professional | | $50.00 | $70.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.00 / $3,085.00 / $5,060.00
| Facility | | $755.00 | $3,085.00 | $5,060.00 |