- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.16 / $7,182.00 / $14,904.64
| Facility | | $412.16 | $7,182.00 | $14,904.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $564.09 / $1,505.00
| Professional | | $300.00 | $564.09 | $1,505.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.29 / $280.37 / $434.25
| Facility | | $144.29 | $280.37 | $434.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.93 / $1,917.93 / $1,917.93
| Professional | | $1,917.93 | $1,917.93 | $1,917.93 |
- 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 |