- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.53 / $3,038.00 / $4,387.00
| Facility | | $1,689.53 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.53 / $1,689.53 / $1,689.53
| Professional | | $1,689.53 | $1,689.53 | $1,689.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.83 / $377.82 / $550.59
| Facility | | $281.83 | $377.82 | $550.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |