- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.00 / $1,342.00 / $3,804.00
| Facility | | $920.00 | $1,342.00 | $3,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.00 / $1,305.00 / $1,846.00
| Professional | | $1,305.00 | $1,305.00 | $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
- $61.87 / $61.87 / $61.87
| Facility | | $61.87 | $61.87 | $61.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $811.00 / $2,285.00
| Facility | | $330.00 | $811.00 | $2,285.00 |