- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.00 / $430.00 / $430.00
| Professional | | $430.00 | $430.00 | $430.00 |
- 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
- $1,321.02 / $2,433.44 / $5,454.00
| Facility | | $1,321.02 | $2,433.44 | $5,454.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $3,482.00 / $5,454.00
| Facility | | $1,321.00 | $3,482.00 | $5,454.00 |