- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.28 / $195.28 / $198.46
| Professional | | $195.28 | $195.28 | $198.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $300.19 / $370.21
| Professional | | $184.84 | $300.19 | $370.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,631.30 / $27,631.30 / $27,631.30
| Facility | | $27,631.30 | $27,631.30 | $27,631.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.70 / $343.99 / $467.84
| Professional | | $208.70 | $343.99 | $467.84 |