- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.00 / $5,287.77 / $10,134.00
| Facility | | $1,245.00 | $5,287.77 | $10,134.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.65 / $1,058.65 / $1,058.65
| Professional | | $1,058.65 | $1,058.65 | $1,058.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.10 / $500.10 / $500.10
| Professional | | $500.10 | $500.10 | $500.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,293.00 / $12,216.00 / $19,066.00
| Facility | | $5,293.00 | $12,216.00 | $19,066.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,160.00 / $10,160.00 / $10,160.00
| Facility | | $10,160.00 | $10,160.00 | $10,160.00 |