- 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
- $510.80 / $510.80 / $513.58
| Professional | | $510.80 | $510.80 | $513.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.04 / $642.58 / $785.22
| Professional | | $433.04 | $642.58 | $785.22 |
- 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
- $436.54 / $540.12 / $1,180.28
| Professional | | $436.54 | $540.12 | $1,180.28 |