- 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
- $523.26 / $527.52 / $527.52
| Professional | | $523.26 | $527.52 | $527.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.69 / $678.58 / $971.99
| Professional | | $491.69 | $678.58 | $971.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.87 / $632.65 / $1,198.19
| Professional | | $488.87 | $632.65 | $1,198.19 |