- 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
- $94.60 / $151.52 / $176.24
| Professional | | $94.60 | $151.52 | $176.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.86 / $407.86 / $407.86
| Facility | | $407.86 | $407.86 | $407.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.87 / $176.28 / $296.42
| Professional | | $104.87 | $176.28 | $296.42 |
- 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
- $145.44 / $204.26 / $370.13
| Professional | | $145.44 | $204.26 | $370.13 |