- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.40 / $2,038.32 / $3,140.00
| Facility | | $11.40 | $2,038.32 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.00 / $1,686.00 / $4,573.00
| Professional | | $1,686.00 | $1,686.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,025.00 / $3,025.00 / $3,025.00
| Facility | | $3,025.00 | $3,025.00 | $3,025.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,177.71 / $2,177.71 / $4,695.00
| Facility | | $2,177.71 | $2,177.71 | $4,695.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.00 / $1,320.00 / $1,320.00
| Facility | | $414.00 | $1,320.00 | $1,320.00 |