- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,592.00 / $5,063.00 / $9,488.00
| Facility | | $4,592.00 | $5,063.00 | $9,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,592.00 / $5,063.00 / $7,631.00
| Professional | | $4,592.00 | $5,063.00 | $7,631.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.27 / $3,801.18 / $7,114.08
| Facility | | $1,282.27 | $3,801.18 | $7,114.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.43 / $269.95 / $269.95
| Professional | | $250.43 | $269.95 | $269.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.00 / $3,629.00 / $10,000.00
| Facility | | $607.00 | $3,629.00 | $10,000.00 |