- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,421.00 / $4,604.83 / $7,119.04
| Facility | | $3,421.00 | $4,604.83 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.28 / $1,523.28 / $1,523.28
| Professional | | $1,523.28 | $1,523.28 | $1,523.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.70 / $661.74 / $2,338.00
| Facility | | $313.70 | $661.74 | $2,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,607.00 / $2,126.00
| Facility | | $1,204.00 | $1,607.00 | $2,126.00 |