- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.82 / $342.64 / $643.22
| Facility | | $252.82 | $342.64 | $643.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.89 / $72.89 / $72.89
| Facility | | $72.89 | $72.89 | $72.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.00 / $131.44 / $150.08
| Facility | | $78.00 | $131.44 | $150.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.89 / $85.03 / $117.10
| Facility | | $72.89 | $85.03 | $117.10 |