- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.00 / $4,732.00 / $11,576.00
| Facility | | $1,068.00 | $4,732.00 | $11,576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.00 / $4,729.00 / $11,576.00
| Professional | | $551.00 | $4,729.00 | $11,576.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.00 / $323.00 / $323.00
| Facility | | $323.00 | $323.00 | $323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.00 / $12,923.00 / $19,866.00
| Facility | | $4,072.00 | $12,923.00 | $19,866.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.02 / $207.02 / $207.02
| Professional | | $207.02 | $207.02 | $207.02 |