- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.27 / $398.53 / $398.53
| Professional | | $346.27 | $398.53 | $398.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.40 / $1,076.40 / $1,076.40
| Facility | | $1,076.40 | $1,076.40 | $1,076.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.47 / $411.36 / $721.28
| Professional | | $353.47 | $411.36 | $721.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.40 / $426.00 / $887.91
| Professional | | $328.40 | $426.00 | $887.91 |