- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,052.40 / $16,052.40 / $16,052.40
| Facility | | $16,052.40 | $16,052.40 | $16,052.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.46 / $1,165.20 / $9,997.10
| Professional | | $665.46 | $1,165.20 | $9,997.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.00 / $1,000.00 / $1,214.19
| Professional | | $975.00 | $1,000.00 | $1,214.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $813.00 / $1,000.00 / $1,010.00
| Facility | | $813.00 | $1,000.00 | $1,010.00 |
- 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 |