- 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
- $89.87 / $133.06 / $203.72
| Professional | | $89.87 | $133.06 | $203.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $418.00 / $418.00
| Facility | | $418.00 | $418.00 | $418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.68 / $147.71 / $202.46
| Professional | | $91.68 | $147.71 | $202.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.94 / $166.78 / $396.48
| Professional | | $133.94 | $166.78 | $396.48 |