- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,949.00 / $3,949.00 / $6,907.00
| Facility | | $3,949.00 | $3,949.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.32 / $473.39 / $473.39
| Professional | | $461.32 | $473.39 | $473.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.91 / $552.02 / $872.24
| Professional | | $403.91 | $552.02 | $872.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.58 / $567.08 / $1,042.21
| Professional | | $379.58 | $567.08 | $1,042.21 |