- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $1,846.00 / $9,477.00
| Facility | | $1,181.00 | $1,846.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.00 / $1,846.00 / $1,846.00
| Professional | | $1,846.00 | $1,846.00 | $1,846.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.35 / $588.35 / $706.02
| Facility | | $588.35 | $588.35 | $706.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.31 / $2,681.31 / $2,681.31
| Facility | | $2,681.31 | $2,681.31 | $2,681.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $811.00 / $1,574.00
| Facility | | $330.00 | $811.00 | $1,574.00 |