- 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
- $619.37 / $703.88 / $746.46
| Professional | | $619.37 | $703.88 | $746.46 |
- 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
- $454.04 / $560.58 / $899.37
| Professional | | $454.04 | $560.58 | $899.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.54 / $545.57 / $1,405.89
| Professional | | $436.54 | $545.57 | $1,405.89 |