- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $3,977.00 / $5,743.00
| Facility | | $3,038.00 | $3,977.00 | $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
- $1,029.45 / $1,334.02 / $1,944.04
| Facility | | $1,029.45 | $1,334.02 | $1,944.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.00 / $2,790.00 / $4,912.00
| Facility | | $658.00 | $2,790.00 | $4,912.00 |