- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $5,295.30 / $6,907.00
| Facility | | $3,140.00 | $5,295.30 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.80 / $114.04 / $197.50
| Professional | | $110.80 | $114.04 | $197.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.33 / $179.58 / $259.45
| Professional | | $126.33 | $179.58 | $259.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.05 / $222.66 / $3,045.66
| Facility | | $211.05 | $222.66 | $3,045.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.30 / $194.71 / $448.01
| Professional | | $136.30 | $194.71 | $448.01 |