- 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
- $33.61 / $33.67 / $34.51
| Professional | | $33.61 | $33.67 | $34.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.06 / $44.24 / $61.92
| Professional | | $31.06 | $44.24 | $61.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.80 / $1,185.80 / $2,829.62
| Facility | | $1,185.80 | $1,185.80 | $2,829.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $48.04 / $81.11
| Professional | | $35.00 | $48.04 | $81.11 |