- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $2,080.00 / $4,100.00
| Facility | | $1,017.00 | $2,080.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.55 / $101.55 / $101.55
| Professional | | $101.55 | $101.55 | $101.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.35 / $57.35 / $1,021.00
| Professional | | $57.35 | $57.35 | $1,021.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.04 / $210.10 / $210.10
| Professional | | $97.04 | $210.10 | $210.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $442.00 / $5,940.00
| Facility | | $165.00 | $442.00 | $5,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.17 / $109.12 / $245.46
| Professional | | $71.17 | $109.12 | $245.46 |