- 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
- $112.38 / $149.46 / $182.73
| Professional | | $112.38 | $149.46 | $182.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.73 / $180.72 / $256.91
| Professional | | $121.73 | $180.72 | $256.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.64 / $188.64 / $188.64
| Professional | | $188.64 | $188.64 | $188.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.61 / $211.78 / $471.09
| Professional | | $168.61 | $211.78 | $471.09 |