- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,870.00 / $3,294.00 / $4,387.00
| Facility | | $2,870.00 | $3,294.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.00 / $2,843.00 / $4,387.00
| Professional | | $1,023.00 | $2,843.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $288.47
| Professional | | $45.00 | $45.00 | $288.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,370.62 / $10,940.20 / $15,943.01
| Facility | | $8,370.62 | $10,940.20 | $15,943.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.00 / $9,753.00 / $15,824.00
| Facility | | $1,680.00 | $9,753.00 | $15,824.00 |