- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,463.36 / $12,262.01
| Facility | | $3,496.00 | $5,463.36 | $12,262.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.00 / $2,075.92 / $2,075.92
| Professional | | $672.00 | $2,075.92 | $2,075.92 |
- 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
- $7,413.26 / $11,495.00 / $15,899.59
| Facility | | $7,413.26 | $11,495.00 | $15,899.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,379.00 / $10,799.94 / $14,983.56
| Facility | | $7,379.00 | $10,799.94 | $14,983.56 |