- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $512.86
| Professional | | $199.53 | $199.53 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $302.00 / $371.54
| Professional | | $186.21 | $302.00 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $27,542.29 / $27,542.29
| Facility | | $27,542.29 | $27,542.29 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $331.13 / $478.63
| Professional | | $208.93 | $331.13 | $478.63 |