- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.06 / $1,248.06 / $4,237.72
| Facility | | $1,248.06 | $1,248.06 | $4,237.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.40 / $397.49 / $450.00
| Professional | | $155.40 | $397.49 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.00 / $1,712.00 / $1,712.00
| Professional | | $1,712.00 | $1,712.00 | $1,712.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $599.00 / $2,530.00
| Facility | | $582.00 | $599.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $453.00 / $1,330.00
| Facility | | $418.00 | $453.00 | $1,330.00 |