- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.00 / $1,831.00 / $2,825.00
| Facility | | $784.00 | $1,831.00 | $2,825.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,158.76 / $4,158.76 / $4,158.76
| Facility | | $4,158.76 | $4,158.76 | $4,158.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.65 / $1,622.65 / $1,622.65
| Professional | | $1,622.65 | $1,622.65 | $1,622.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,918.22 / $2,918.22 / $2,918.22
| Facility | | $2,918.22 | $2,918.22 | $2,918.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.00 / $2,148.00 / $6,612.00
| Facility | | $700.00 | $2,148.00 | $6,612.00 |