- 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
- $71.04 / $161.41 / $227.08
| Professional | | $71.04 | $161.41 | $227.08 |
- 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
- $62.36 / $147.80 / $208.89
| Professional | | $62.36 | $147.80 | $208.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.72 / $190.17 / $407.51
| Professional | | $150.72 | $190.17 | $407.51 |