- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $10,255.42
| Facility | | $5,012.00 | $6,298.62 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,002.00 / $7,002.00 / $7,002.00
| Professional | | $7,002.00 | $7,002.00 | $7,002.00 |
- 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 / $5,244.00 / $7,856.00
| Facility | | $2,126.00 | $5,244.00 | $7,856.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,856.00
| Facility | | $2,126.00 | $5,847.00 | $7,856.00 |