- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.00 / $3,382.00 / $4,707.00
| Facility | | $1,691.00 | $3,382.00 | $4,707.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.20 / $55.20 / $4,050.00
| Facility | | $55.20 | $55.20 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.20 / $55.20 / $131.59
| Professional | | $55.20 | $55.20 | $131.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.37 / $656.37 / $656.37
| Professional | | $656.37 | $656.37 | $656.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.90 / $66.31 / $144.87
| Professional | | $52.90 | $66.31 | $144.87 |