- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.67 / $3,352.80 / $3,352.80
| Facility | | $362.67 | $3,352.80 | $3,352.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.25 / $157.25 / $157.25
| Professional | | $157.25 | $157.25 | $157.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $32.34 / $3,500.00
| Professional | | $30.00 | $32.34 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.73 / $386.99 / $485.01
| Facility | | $270.73 | $386.99 | $485.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $8,244.00 / $9,193.00
| Facility | | $1,800.00 | $8,244.00 | $9,193.00 |