- 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
- $95.15 / $113.31 / $222.64
| Professional | | $95.15 | $113.31 | $222.64 |
- 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
- $82.14 / $138.44 / $206.68
| Professional | | $82.14 | $138.44 | $206.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.75 / $170.09 / $397.73
| Professional | | $143.75 | $170.09 | $397.73 |