- 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
- $254.08 / $300.97 / $527.47
| Professional | | $254.08 | $300.97 | $527.47 |
- 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
- $220.22 / $370.23 / $492.51
| Professional | | $220.22 | $370.23 | $492.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.73 / $437.10 / $974.43
| Professional | | $358.73 | $437.10 | $974.43 |