- 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
- $122.77 / $156.35 / $239.27
| Professional | | $122.77 | $156.35 | $239.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $418.00 / $418.00
| Facility | | $418.00 | $418.00 | $418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.58 / $165.21 / $229.20
| Professional | | $109.58 | $165.21 | $229.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.10 / $182.10 / $443.10
| Professional | | $143.10 | $182.10 | $443.10 |