- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.47 / $642.20 / $686.85
| Professional | | $515.47 | $642.20 | $686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.00 / $790.00 / $790.00
| Facility | | $790.00 | $790.00 | $790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.78 / $492.44 / $752.66
| Professional | | $452.78 | $492.44 | $752.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.10 / $521.78 / $1,261.63
| Professional | | $435.10 | $521.78 | $1,261.63 |