- 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
- $258.10 / $294.47 / $368.73
| Professional | | $258.10 | $294.47 | $368.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $418.00 / $418.00
| Facility | | $418.00 | $418.00 | $418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.82 / $267.47 / $434.01
| Professional | | $213.82 | $267.47 | $434.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $291.77 / $353.72
| Professional | | $251.77 | $291.77 | $353.72 |