- 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
- $152.27 / $302.38 / $350.53
| Professional | | $152.27 | $302.38 | $350.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.37 / $524.37 / $524.37
| Facility | | $524.37 | $524.37 | $524.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.02 / $287.45 / $535.10
| Professional | | $143.02 | $287.45 | $535.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.00 / $440.00 / $440.00
| Facility | | $440.00 | $440.00 | $440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.37 / $377.59 / $817.32
| Professional | | $278.37 | $377.59 | $817.32 |