- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $4,014.00 / $5,743.00
| Facility | | $3,038.00 | $4,014.00 | $5,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $4,387.00
| Professional | | $2,843.00 | $2,843.00 | $4,387.00 |
- 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
- $1,106.00 / $1,649.00 / $2,824.00
| Facility | | $1,106.00 | $1,649.00 | $2,824.00 |