- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,760.83 / $7,244.36
| Facility | | $6,606.93 | $6,760.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,949.84
| Professional | | $758.58 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $758.58 / $1,513.56
| Professional | | $741.31 | $758.58 | $1,513.56 |
- 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
- $691.83 / $870.96 / $1,047.13
| Professional | | $691.83 | $870.96 | $1,047.13 |