- 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
- $109.27 / $162.80 / $171.21
| Professional | | $109.27 | $162.80 | $171.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.06 / $170.36 / $240.13
| Professional | | $118.06 | $170.36 | $240.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,150.78 / $7,150.78 / $7,150.78
| Facility | | $7,150.78 | $7,150.78 | $7,150.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.82 / $202.18 / $384.82
| Professional | | $156.82 | $202.18 | $384.82 |