- 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
- $296.98 / $360.26 / $406.82
| Professional | | $296.98 | $360.26 | $406.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.86 / $428.14 / $606.03
| Professional | | $291.86 | $428.14 | $606.03 |
- 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
- $344.07 / $497.03 / $923.76
| Professional | | $344.07 | $497.03 | $923.76 |