- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.00 / $2,209.58 / $5,261.87
| Facility | | $1,664.00 | $2,209.58 | $5,261.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.98 / $993.21 / $1,662.53
| Professional | | $828.98 | $993.21 | $1,662.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $345.40 / $345.40
| Professional | | $100.00 | $345.40 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $40.00
| Professional | | $30.00 | $30.00 | $40.00 |