- 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
- $88.56 / $105.47 / $158.49
| Professional | | $88.56 | $105.47 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.46 / $143.10 / $203.75
| Professional | | $93.46 | $143.10 | $203.75 |
- 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
- $113.11 / $148.50 / $321.29
| Professional | | $113.11 | $148.50 | $321.29 |