- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Facility | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $1,258.93
| Professional | | $467.74 | $575.44 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $851.14
| Professional | | $436.52 | $588.84 | $851.14 |
- 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
- $398.11 / $537.03 / $851.14
| Professional | | $398.11 | $537.03 | $851.14 |