- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,393.00 / $5,549.00 / $10,506.16
| Facility | | $4,393.00 | $5,549.00 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,390.00 / $5,390.00 / $5,390.00
| Professional | | $5,390.00 | $5,390.00 | $5,390.00 |
- 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
- $336.50 / $707.16 / $2,126.00
| Facility | | $336.50 | $707.16 | $2,126.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,607.00 / $2,126.00
| Facility | | $1,204.00 | $1,607.00 | $2,126.00 |