- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.24 / $4,387.50 / $8,705.66
| Facility | | $563.24 | $4,387.50 | $8,705.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $3,306.43
| Professional | | $402.32 | $402.32 | $3,306.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $792.00 / $2,924.00
| Facility | | $582.00 | $792.00 | $2,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.42 / $104.42 / $104.42
| Facility | | $104.42 | $104.42 | $104.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |