- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.00 / $4,500.00 / $7,045.00
| Facility | | $1,407.00 | $4,500.00 | $7,045.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.52 / $1,689.52 / $1,942.95
| Professional | | $1,689.52 | $1,689.52 | $1,942.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,500.00
| Professional | | $30.00 | $55.00 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.42 / $472.21 / $603.75
| Facility | | $330.42 | $472.21 | $603.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $8,244.00 / $9,193.00
| Facility | | $1,800.00 | $8,244.00 | $9,193.00 |