- 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
- $162.28 / $182.19 / $251.25
| Professional | | $162.28 | $182.19 | $251.25 |
- 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
- $150.47 / $252.71 / $361.18
| Professional | | $150.47 | $252.71 | $361.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.00 / $440.00 / $5,000.00
| Facility | | $440.00 | $440.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.46 / $292.20 / $471.69
| Professional | | $174.46 | $292.20 | $471.69 |