- 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
- $187.79 / $187.79 / $214.67
| Professional | | $187.79 | $187.79 | $214.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.68 / $259.68 / $369.60
| Professional | | $192.68 | $259.68 | $369.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,130.85 / $5,130.85 / $7,655.13
| Facility | | $5,130.85 | $5,130.85 | $7,655.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.83 / $261.20 / $478.95
| Professional | | $201.83 | $261.20 | $478.95 |