- 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
- $93.84 / $142.28 / $219.66
| Professional | | $93.84 | $142.28 | $219.66 |
- 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
- $82.53 / $147.09 / $203.61
| Professional | | $82.53 | $147.09 | $203.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.97 / $171.85 / $401.73
| Professional | | $139.97 | $171.85 | $401.73 |