- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,530.01 / $3,530.01 / $6,907.00
| Facility | | $3,530.01 | $3,530.01 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.71 / $240.71 / $309.83
| Professional | | $163.71 | $240.71 | $309.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.83 / $183.83 / $1,881.00
| Facility | | $183.83 | $183.83 | $1,881.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.28 / $245.93 / $410.78
| Professional | | $171.28 | $245.93 | $410.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.00 / $1,320.00 / $1,320.00
| Facility | | $414.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.85 / $265.64 / $601.20
| Professional | | $219.85 | $265.64 | $601.20 |