- 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
- $227.19 / $237.26 / $237.26
| Professional | | $227.19 | $237.26 | $237.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.58 / $264.11 / $465.09
| Professional | | $213.58 | $264.11 | $465.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.34 / $292.73 / $571.40
| Professional | | $211.34 | $292.73 | $571.40 |