- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.78 / $153.78 / $166.02
| Professional | | $153.78 | $153.78 | $166.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $182.71 / $316.35
| Professional | | $149.72 | $182.71 | $316.35 |
- 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
- $147.61 / $193.74 / $399.10
| Professional | | $147.61 | $193.74 | $399.10 |