- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,776.00 / $9,062.00 / $23,966.60
| Facility | | $3,776.00 | $9,062.00 | $23,966.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.00 / $2,903.60 / $2,903.60
| Professional | | $68.00 | $2,903.60 | $2,903.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.13 / $289.77 / $481.91
| Facility | | $144.13 | $289.77 | $481.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $1,221.00 / $3,585.00
| Facility | | $225.00 | $1,221.00 | $3,585.00 |