- 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
- $2,546.00 / $2,546.00 / $2,546.00
| Professional | | $2,546.00 | $2,546.00 | $2,546.00 |
- 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
- $1,026.00 / $1,623.00 / $3,560.25
| Facility | | $1,026.00 | $1,623.00 | $3,560.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.00 / $1,640.00 / $3,560.25
| Facility | | $1,151.00 | $1,640.00 | $3,560.25 |