- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.69 / $406.69 / $508.36
| Professional | | $406.69 | $406.69 | $508.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,607.65 / $12,000.00 / $12,000.00
| Facility | | $6,607.65 | $12,000.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.00 / $1,496.00 / $1,496.00
| Professional | | $1,496.00 | $1,496.00 | $1,496.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.12 / $315.77 / $453.47
| Facility | | $251.12 | $315.77 | $453.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.00 / $327.00 / $327.00
| Professional | | $327.00 | $327.00 | $327.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.12 / $315.77 / $453.47
| Facility | | $251.12 | $315.77 | $453.47 |