- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,028.00 / $9,477.00
| Facility | | $1,181.00 | $2,028.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.35 / $2,678.35 / $2,678.35
| Professional | | $2,678.35 | $2,678.35 | $2,678.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.37 / $211.37 / $253.64
| Facility | | $211.37 | $211.37 | $253.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.28 / $116.28 / $116.28
| Facility | | $116.28 | $116.28 | $116.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $345.00 / $768.00
| Facility | | $130.00 | $345.00 | $768.00 |