- 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
- $140.35 / $217.54 / $284.20
| Professional | | $140.35 | $217.54 | $284.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.67 / $164.67 / $1,404.00
| Facility | | $164.67 | $164.67 | $1,404.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.83 / $225.49 / $362.65
| Professional | | $147.83 | $225.49 | $362.65 |
- 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
- $193.73 / $257.47 / $532.66
| Professional | | $193.73 | $257.47 | $532.66 |