- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.59 / $785.59 / $841.71
| Professional | | $785.59 | $785.59 | $841.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.84 / $1,092.83 / $1,289.98
| Professional | | $786.84 | $1,092.83 | $1,289.98 |
- 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
- $801.18 / $1,011.90 / $1,973.20
| Professional | | $801.18 | $1,011.90 | $1,973.20 |