- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $5,691.53 / $6,407.13
| Facility | | $1,350.00 | $5,691.53 | $6,407.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.40 / $3,750.00 / $4,311.00
| Professional | | $426.40 | $3,750.00 | $4,311.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $53.50 / $53.50
| Facility | | $50.00 | $53.50 | $53.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,492.00 / $13,946.00 / $21,454.00
| Facility | | $6,492.00 | $13,946.00 | $21,454.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |