- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $6,298.62 / $12,885.00
| Facility | | $3,496.00 | $6,298.62 | $12,885.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,014.00 / $4,014.00 / $4,014.00
| Professional | | $4,014.00 | $4,014.00 | $4,014.00 |
- 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
- $2,126.00 / $5,847.00 / $7,407.10
| Facility | | $2,126.00 | $5,847.00 | $7,407.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |