- 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
- $477.37 / $548.73 / $548.73
| Professional | | $477.37 | $548.73 | $548.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.41 / $545.09 / $974.12
| Professional | | $478.41 | $545.09 | $974.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.47 / $515.41 / $1,236.83
| Professional | | $445.47 | $515.41 | $1,236.83 |