- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.00 / $1,313.00 / $3,109.00
| Facility | | $626.00 | $1,313.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,636.40 / $2,636.40 / $2,636.40
| Professional | | $2,636.40 | $2,636.40 | $2,636.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.54 / $210.54 / $252.65
| Facility | | $210.54 | $210.54 | $252.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.26 / $167.26 / $167.26
| Facility | | $167.26 | $167.26 | $167.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $328.00 / $858.00
| Facility | | $130.00 | $328.00 | $858.00 |