- 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
- $101.73 / $158.84 / $165.19
| Professional | | $101.73 | $158.84 | $165.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.76 / $155.31 / $220.78
| Professional | | $110.76 | $155.31 | $220.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.15 / $164.15 / $164.15
| Professional | | $164.15 | $164.15 | $164.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.09 / $169.85 / $261.88
| Professional | | $146.09 | $169.85 | $261.88 |