- 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
- $102.35 / $135.47 / $182.30
| Professional | | $102.35 | $135.47 | $182.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.15 / $164.77 / $280.23
| Professional | | $98.15 | $164.77 | $280.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,188.37 / $9,188.37 / $9,188.37
| Facility | | $9,188.37 | $9,188.37 | $9,188.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.26 / $202.22 / $410.67
| Professional | | $156.26 | $202.22 | $410.67 |