- 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
- $176.00 / $176.00 / $176.00
| Professional | | $176.00 | $176.00 | $176.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.27 / $46.23 / $77.44
| Facility | | $19.27 | $46.23 | $77.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.08 / $1,327.00 / $1,327.00
| Facility | | $397.08 | $1,327.00 | $1,327.00 |