- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,230.00 / $5,866.00 / $13,453.87
| Facility | | $4,230.00 | $5,866.00 | $13,453.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.45 / $317.45 / $317.45
| Professional | | $317.45 | $317.45 | $317.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.47 / $298.54 / $462.31
| Facility | | $153.47 | $298.54 | $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 |