- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $2,238.72
| Professional | | $776.25 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,548.82
| Professional | | $812.83 | $1,096.48 | $1,548.82 |
- 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
- $741.31 / $1,000.00 / $1,479.11
| Professional | | $741.31 | $1,000.00 | $1,479.11 |