- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,311.00 / $4,069.00 / $7,602.00
| Facility | | $2,311.00 | $4,069.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,520.23 / $3,520.23
| Professional | | $3,520.23 | $3,520.23 | $3,520.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.00 / $150.00 / $2,367.00
| Facility | | $110.00 | $150.00 | $2,367.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Facility | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |