- 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
- $129.33 / $203.59 / $203.59
| Professional | | $129.33 | $203.59 | $203.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.71 / $198.33 / $281.94
| Professional | | $129.71 | $198.33 | $281.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.89 / $208.89 / $228.93
| Professional | | $208.89 | $208.89 | $228.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.47 / $233.29 / $528.53
| Professional | | $165.47 | $233.29 | $528.53 |