- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,164.00 / $3,278.00 / $4,387.00
| Facility | | $2,164.00 | $3,278.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.83 / $454.88 / $923.31
| Professional | | $230.83 | $454.88 | $923.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,312.82 / $1,732.91 / $2,525.35
| Facility | | $1,312.82 | $1,732.91 | $2,525.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $2,312.00 / $4,640.00
| Facility | | $1,689.00 | $2,312.00 | $4,640.00 |