- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.85 / $6,213.00 / $16,449.00
| Facility | | $2,719.85 | $6,213.00 | $16,449.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $2,719.85 / $2,719.85
| Professional | | $40.00 | $2,719.85 | $2,719.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $24.00 / $24.00
| Professional | | $24.00 | $24.00 | $24.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $2,736.31
| Professional | | $45.00 | $45.00 | $2,736.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |