- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.09 / $660.09 / $660.09
| Professional | | $660.09 | $660.09 | $660.09 |
- 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
- $352.42 / $740.60 / $2,126.00
| Facility | | $352.42 | $740.60 | $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 |