- 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
- $333.81 / $348.62 / $348.62
| Professional | | $333.81 | $348.62 | $348.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.54 / $394.31 / $689.59
| Professional | | $314.54 | $394.31 | $689.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $500.00
| Facility | | $143.00 | $143.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.01 / $430.02 / $840.89
| Professional | | $311.01 | $430.02 | $840.89 |