- 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
- $123.65 / $166.40 / $176.60
| Professional | | $123.65 | $166.40 | $176.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.08 / $100.08 / $100.08
| Facility | | $100.08 | $100.08 | $100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.07 / $191.86 / $318.44
| Professional | | $142.07 | $191.86 | $318.44 |
- 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
- $150.43 / $204.53 / $403.29
| Professional | | $150.43 | $204.53 | $403.29 |