- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.45 / $976.82 / $976.82
| Professional | | $854.45 | $976.82 | $976.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.98 / $1,124.83 / $1,765.52
| Professional | | $850.98 | $1,124.83 | $1,765.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.62 / $1,159.83 / $2,271.44
| Professional | | $892.62 | $1,159.83 | $2,271.44 |