- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,441.03 / $6,907.00
| Facility | | $3,140.00 | $3,441.03 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.52 / $168.77 / $226.52
| Professional | | $47.52 | $168.77 | $226.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.61 / $96.58 / $294.27
| Professional | | $48.61 | $96.58 | $294.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.99 / $197.44 / $463.39
| Professional | | $144.99 | $197.44 | $463.39 |