- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $162.18 / $354.81
| Professional | | $100.00 | $162.18 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $169.82 / $263.03
| Professional | | $104.71 | $169.82 | $263.03 |
- 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
- $104.71 / $158.49 / $245.47
| Professional | | $104.71 | $158.49 | $245.47 |