- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $11,100.08
| Facility | | $4,277.00 | $6,066.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.20 / $805.20 / $805.20
| Professional | | $805.20 | $805.20 | $805.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.44 / $110.01 / $197.49
| Professional | | $94.44 | $110.01 | $197.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.20 / $1,360.79 / $7,123.00
| Facility | | $805.20 | $1,360.79 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,856.00
| Facility | | $2,126.00 | $5,847.00 | $7,856.00 |