- 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
- $98.62 / $153.40 / $274.58
| Professional | | $98.62 | $153.40 | $274.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $1,404.00
| Facility | | $141.60 | $141.60 | $1,404.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.21 / $160.61 / $283.64
| Professional | | $104.21 | $160.61 | $283.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $143.00 / $143.00
| Facility | | $104.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.78 / $181.34 / $394.48
| Professional | | $146.78 | $181.34 | $394.48 |