- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $7,977.71 / $7,977.71
| Facility | | $3,140.00 | $7,977.71 | $7,977.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.25 / $1,613.00 / $4,573.00
| Professional | | $411.25 | $1,613.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.00 / $2,065.00 / $2,514.05
| Facility | | $2,065.00 | $2,065.00 | $2,514.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.00 / $440.00 / $440.00
| Facility | | $250.00 | $440.00 | $440.00 |