- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,464.52 / $5,464.52 / $16,467.00
| Facility | | $5,464.52 | $5,464.52 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.59 / $72.59 / $6,188.00
| Professional | | $72.59 | $72.59 | $6,188.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.16 / $294.10 / $462.31
| Facility | | $147.16 | $294.10 | $462.31 |
- 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 |