- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.24 / $6,907.00 / $9,807.24
| Facility | | $1,547.24 | $6,907.00 | $9,807.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.04 / $602.04 / $644.05
| Professional | | $577.04 | $602.04 | $644.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.79 / $837.72 / $988.58
| Professional | | $598.79 | $837.72 | $988.58 |
- 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
- $574.59 / $763.92 / $1,502.14
| Professional | | $574.59 | $763.92 | $1,502.14 |