- 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
- $638.10 / $724.53 / $767.92
| Professional | | $638.10 | $724.53 | $767.92 |
- 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
- $526.30 / $577.57 / $926.34
| Professional | | $526.30 | $577.57 | $926.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $590.15 / $1,447.13
| Professional | | $501.19 | $590.15 | $1,447.13 |