- 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
- $70.79 / $114.82 / $251.19
| Professional | | $70.79 | $114.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $117.49 / $165.96
| Professional | | $77.62 | $117.49 | $165.96 |
- 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
- $74.13 / $104.71 / $165.96
| Professional | | $74.13 | $104.71 | $165.96 |