- 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
- $419.38 / $511.70 / $741.08
| Professional | | $419.38 | $511.70 | $741.08 |
- 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
- $362.58 / $477.62 / $752.72
| Professional | | $362.58 | $477.62 | $752.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.12 / $534.96 / $1,361.33
| Professional | | $438.12 | $534.96 | $1,361.33 |