- 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
- $79.84 / $104.29 / $127.70
| Professional | | $79.84 | $104.29 | $127.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.59 / $125.23 / $178.59
| Professional | | $85.59 | $125.23 | $178.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,676.38 / $5,676.38 / $5,676.38
| Facility | | $5,676.38 | $5,676.38 | $5,676.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.04 / $145.38 / $285.88
| Professional | | $114.04 | $145.38 | $285.88 |