- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,401.69 / $2,401.69 / $6,907.00
| Facility | | $2,401.69 | $2,401.69 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.30 / $242.60 / $292.58
| Professional | | $177.30 | $242.60 | $292.58 |
- 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
- $177.37 / $203.55 / $345.83
| Professional | | $177.37 | $203.55 | $345.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.03 / $229.66 / $548.05
| Professional | | $188.03 | $229.66 | $548.05 |