- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.61 / $328.61 / $328.61
| Facility | | $328.61 | $328.61 | $328.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,562.00 / $7,416.94 / $12,345.38
| Facility | | $5,562.00 | $7,416.94 | $12,345.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.74 / $565.58 / $565.58
| Professional | | $480.74 | $565.58 | $565.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.83 / $5,134.00 / $17,464.00
| Facility | | $273.83 | $5,134.00 | $17,464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.00 / $490.00 / $490.00
| Professional | | $490.00 | $490.00 | $490.00 |