- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.50 / $2,624.00 / $9,805.52
| Facility | | $907.50 | $2,624.00 | $9,805.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.00 / $2,624.00 / $7,655.00
| Professional | | $1,361.00 | $2,624.00 | $7,655.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.00 / $624.00 / $624.00
| Facility | | $624.00 | $624.00 | $624.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $416.00 / $1,661.00
| Facility | | $55.00 | $416.00 | $1,661.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.00 / $853.00 / $1,915.00
| Facility | | $376.00 | $853.00 | $1,915.00 |