- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $218.78 / $446.68
| Professional | | $120.23 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $204.17 / $380.19
| Professional | | $117.49 | $204.17 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $181.97 / $302.00
| Professional | | $107.15 | $181.97 | $302.00 |