- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,101.00 / $3,109.00
| Facility | | $1,181.00 | $2,101.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.00 / $1,846.00 / $2,101.00
| Professional | | $1,846.00 | $1,846.00 | $2,101.00 |
- 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 / $337.00 / $858.00
| Facility | | $130.00 | $337.00 | $858.00 |