- 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
- $233.08 / $278.19 / $325.25
| Professional | | $233.08 | $278.19 | $325.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $143.00 / $143.00
| Facility | | $104.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.63 / $326.76 / $635.39
| Professional | | $248.63 | $326.76 | $635.39 |