- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $147.96 / $147.96
| Professional | | $117.25 | $147.96 | $147.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.37 / $524.37 / $524.37
| Facility | | $524.37 | $524.37 | $524.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.00 / $440.00 / $440.00
| Facility | | $440.00 | $440.00 | $440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.77 / $169.29 / $370.93
| Professional | | $145.77 | $169.29 | $370.93 |