- 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
- $118.01 / $156.94 / $184.45
| Professional | | $118.01 | $156.94 | $184.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.07 / $182.65 / $259.64
| Professional | | $128.07 | $182.65 | $259.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.75 / $190.75 / $190.75
| Professional | | $190.75 | $190.75 | $190.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.56 / $198.61 / $307.39
| Professional | | $149.56 | $198.61 | $307.39 |