- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $1,846.00 / $9,477.00
| Facility | | $1,181.00 | $1,846.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.65 / $1,231.65 / $1,231.65
| Professional | | $1,231.65 | $1,231.65 | $1,231.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,196.23 / $2,196.23 / $2,635.48
| Facility | | $2,196.23 | $2,196.23 | $2,635.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.29 / $590.29 / $590.29
| Facility | | $590.29 | $590.29 | $590.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.00 / $1,230.00 / $2,539.00
| Facility | | $590.00 | $1,230.00 | $2,539.00 |