- 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
- $331.12 / $381.41 / $528.41
| Professional | | $331.12 | $381.41 | $528.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.26 / $335.16 / $549.58
| Professional | | $272.26 | $335.16 | $549.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.73 / $343.38 / $928.42
| Professional | | $302.73 | $343.38 | $928.42 |