- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,776.00 / $5,866.00 / $16,467.00
| Facility | | $3,776.00 | $5,866.00 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.53 / $1,689.53 / $1,757.78
| Professional | | $1,689.53 | $1,689.53 | $1,757.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.61 / $36.61 / $60.14
| Facility | | $19.61 | $36.61 | $60.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.48 / $1,858.48 / $2,027.44
| Facility | | $1,858.48 | $1,858.48 | $2,027.44 |
- 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 |